Provider Demographics
NPI:1770078099
Name:NKEMATABONG, BRIDGET L (BEHAVIOR ANALYST)
Entity type:Individual
Prefix:DR
First Name:BRIDGET
Middle Name:L
Last Name:NKEMATABONG
Suffix:
Gender:F
Credentials:BEHAVIOR ANALYST
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NA
Mailing Address - Street 1:22 KASSY LN
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-6577
Mailing Address - Country:US
Mailing Address - Phone:253-722-9152
Mailing Address - Fax:
Practice Address - Street 1:22 KASSY LN
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-6577
Practice Address - Country:US
Practice Address - Phone:253-722-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002043103K00000X
106S00000X
NC1-20-41106103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty