Provider Demographics
NPI:1528041902
Name:ROACH, BRIDGETTE ANNETTE (PT)
Entity Type:Individual
Prefix:MS
First Name:BRIDGETTE
Middle Name:ANNETTE
Last Name:ROACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BRIDGETTE
Other - Middle Name:ANNETTE
Other - Last Name:SEAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11736 E 520 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-5641
Mailing Address - Country:US
Mailing Address - Phone:918-343-9695
Mailing Address - Fax:
Practice Address - Street 1:101 S MOORE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5047
Practice Address - Country:US
Practice Address - Phone:918-342-6214
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist