Provider Demographics
NPI:1578613113
Name:PINE, BRIDGET (PT 22494)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:
Last Name:PINE
Suffix:
Gender:F
Credentials:PT 22494
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6125
Mailing Address - Country:US
Mailing Address - Phone:407-852-3310
Mailing Address - Fax:407-852-3301
Practice Address - Street 1:3305 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6125
Practice Address - Country:US
Practice Address - Phone:407-852-3310
Practice Address - Fax:407-852-3301
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 22494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT 22494Medicaid