Provider Demographics
NPI:1740571272
Name:BRIDGES, LAVONNE
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152-8015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CHERRYVILLE
Practice Address - State:NC
Practice Address - Zip Code:28021-3418
Practice Address - Country:US
Practice Address - Phone:704-435-6727
Practice Address - Fax:704-435-6730
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0011401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical