Provider Demographics
NPI:1043598113
Name:BRIDGE, MARTHA ALICE (LPC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ALICE
Last Name:BRIDGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 COLONY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-3416
Mailing Address - Country:US
Mailing Address - Phone:210-454-5812
Mailing Address - Fax:
Practice Address - Street 1:3050 COLONY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-3416
Practice Address - Country:US
Practice Address - Phone:210-454-5812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-23
Last Update Date:2011-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04026101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)