Provider Demographics
NPI:1295915387
Name:BRIDGES, KONI BREAUX (LCSW)
Entity type:Individual
Prefix:
First Name:KONI
Middle Name:BREAUX
Last Name:BRIDGES
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 1865
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70664-1865
Mailing Address - Country:US
Mailing Address - Phone:337-625-5664
Mailing Address - Fax:
Practice Address - Street 1:108 STATE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5718
Practice Address - Country:US
Practice Address - Phone:337-625-5664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical