Provider Demographics
NPI:1821632852
Name:BOBO, BRIDGETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:
Last Name:BOBO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-0004
Mailing Address - Country:US
Mailing Address - Phone:314-418-9689
Mailing Address - Fax:
Practice Address - Street 1:11520 SAINT CHARLES ROCK RD STE 103
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2732
Practice Address - Country:US
Practice Address - Phone:314-418-9689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-02
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190398261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical