Provider Demographics
NPI:1316637440
Name:BRIDGES, OLIVIA DIANE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:DIANE
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 HALSTEAD BLVD STE 14-15
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-6986
Mailing Address - Country:US
Mailing Address - Phone:252-698-1393
Mailing Address - Fax:
Practice Address - Street 1:905 HALSTEAD BLVD STE 15
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-6816
Practice Address - Country:US
Practice Address - Phone:252-379-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0168511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical