Provider Demographics
NPI:1255056800
Name:BRIDGHAM, GAYLE DONETTE (PT)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:DONETTE
Last Name:BRIDGHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GAYLE
Other - Middle Name:DONETTE
Other - Last Name:JANY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3334 PENNSYLVANIA AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-2915
Mailing Address - Country:US
Mailing Address - Phone:618-694-7300
Mailing Address - Fax:
Practice Address - Street 1:13550 S OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-5812
Practice Address - Country:US
Practice Address - Phone:314-878-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021018958225100000X
IL070006463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist