Provider Demographics
NPI:1043562531
Name:BRIDGET, MIRIAM (LSW)
Entity Type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:
Last Name:BRIDGET
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 SEXTON RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-6005
Mailing Address - Country:US
Mailing Address - Phone:216-673-5460
Mailing Address - Fax:
Practice Address - Street 1:16600 W SPRAGUE RD
Practice Address - Street 2:SUITE 245
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-6318
Practice Address - Country:US
Practice Address - Phone:440-523-0370
Practice Address - Fax:440-523-0639
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0027180101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health