Provider Demographics
NPI:1679087688
Name:QUEBODEAUX, BRIDGET (MFT)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:QUEBODEAUX
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BARRINGTON AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6416
Mailing Address - Country:US
Mailing Address - Phone:310-403-3540
Mailing Address - Fax:
Practice Address - Street 1:10780 SANTA MONICA BLVD STE 470
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7616
Practice Address - Country:US
Practice Address - Phone:310-475-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT95062106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist