Basic Information
| Provider Information | |||||||||
| NPI: | 1023500923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIDGE | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY | ||||||||
| Address2: | STE 307 | ||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 E KING ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193552574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843187214 | ||||||||
| FaxNumber: | 4843187190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2018 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT026862 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT026862 | 01 | PA | PT LICENSE | OTHER |