Provider Demographics
NPI:1528502341
Name:LOCKE, BRIDGET
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:LOCKE
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 1:2133 NW 19TH DR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-8826
Mailing Address - Country:US
Mailing Address - Phone:772-486-0085
Mailing Address - Fax:
Practice Address - Street 1:2000 SE PORT ST LUCIE BLVD STE B
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5546
Practice Address - Country:US
Practice Address - Phone:772-207-7604
Practice Address - Fax:772-873-9997
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 75631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical