Provider Demographics
NPI:1811768310
Name:BRIDGES, STACEY JILL (COTA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:JILL
Last Name:BRIDGES
Suffix:
Gender:
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4452 OLD PARK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-4745
Mailing Address - Country:US
Mailing Address - Phone:910-232-7616
Mailing Address - Fax:
Practice Address - Street 1:3107 MEETING STREET RD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7980
Practice Address - Country:US
Practice Address - Phone:843-654-7464
Practice Address - Fax:843-654-1903
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14574224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant