Provider Demographics
NPI:1023764701
Name:BRIDGES SPEECH LANGUAGE PATHOLOGY PLLC
Entity type:Organization
Organization Name:BRIDGES SPEECH LANGUAGE PATHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:GIACO
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:405-593-0414
Mailing Address - Street 1:309 GOLD ST APT 12A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1280
Mailing Address - Country:US
Mailing Address - Phone:405-593-0414
Mailing Address - Fax:
Practice Address - Street 1:309 GOLD ST APT 12A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1280
Practice Address - Country:US
Practice Address - Phone:405-593-0414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-22
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05804384Medicaid