1720373954 NPI number — BRIDGETTE COLWELL ATALLAH M.A.

Table of content: BRIDGETTE COLWELL ATALLAH M.A. (NPI 1720373954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720373954 NPI number — BRIDGETTE COLWELL ATALLAH M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ATALLAH
Provider First Name:
BRIDGETTE
Provider Middle Name:
COLWELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLWELL
Provider Other First Name:
BRIDGETTE
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720373954
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
629 CAMINO DE LOS MARES
Provider Second Line Business Mailing Address:
STE 207A
Provider Business Mailing Address City Name:
SAN CLEMENTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92673-2832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-228-9080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
629 CAMINO DE LOS MARES
Provider Second Line Business Practice Location Address:
STE 207A
Provider Business Practice Location Address City Name:
SAN CLEMENTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92673-2832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-228-9080
Provider Business Practice Location Address Fax Number:
844-602-4623
Provider Enumeration Date:
06/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY 26225 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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