1073033460 NPI number — BRIDGET BREANNE HINES MSW, LCSW

Table of content: BRIDGET BREANNE HINES MSW, LCSW (NPI 1073033460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073033460 NPI number — BRIDGET BREANNE HINES MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HINES
Provider First Name:
BRIDGET
Provider Middle Name:
BREANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARVIN
Provider Other First Name:
BRIDGET
Provider Other Middle Name:
BREANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1073033460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15773 85TH PL N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55311-1568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-470-8683
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
426 PHOENIX DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMBERSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17201-4537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-375-4834
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2017

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: 1041C0700X , with the licence number:  CW019360 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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