Provider Demographics
NPI:1972193829
Name:BLACK, BRIDGET NICOLE (AUD)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:NICOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-1817
Mailing Address - Country:US
Mailing Address - Phone:806-799-8950
Mailing Address - Fax:
Practice Address - Street 1:1411 N VALLEY MILLS DR STE F
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4453
Practice Address - Country:US
Practice Address - Phone:254-732-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81298231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist