Provider Demographics
NPI:1720476336
Name:BRIDGE, DEANIE LYNETTE
Entity Type:Individual
Prefix:
First Name:DEANIE
Middle Name:LYNETTE
Last Name:BRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEANIE
Other - Middle Name:LYNETTE
Other - Last Name:PERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:518 28 RD
Mailing Address - Street 2:A101
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6556
Mailing Address - Country:US
Mailing Address - Phone:970-778-2473
Mailing Address - Fax:
Practice Address - Street 1:518 28 RD STE A101
Practice Address - Street 2:A101
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6557
Practice Address - Country:US
Practice Address - Phone:970-778-2473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2017-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015059101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health