Provider Demographics
NPI:1801035977
Name:ELLINGBOE, BRIDGET C (MS)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:C
Last Name:ELLINGBOE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6314 ODANA RD
Mailing Address - Street 2:LSS OF WI & UPPER MI, INC.
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1129
Mailing Address - Country:US
Mailing Address - Phone:608-277-0610
Mailing Address - Fax:608-270-6651
Practice Address - Street 1:6314 ODANA RD
Practice Address - Street 2:LSS OF WI & UPPER MI, INC.
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1129
Practice Address - Country:US
Practice Address - Phone:608-277-0610
Practice Address - Fax:608-270-6651
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI105228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist