Provider Demographics
NPI:1053066423
Name:BAINBRIDGE, MARIAH
Entity Type:Individual
Prefix:MRS
First Name:MARIAH
Middle Name:
Last Name:BAINBRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:
Other - Last Name:GAVANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:821 DAIMLER DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 340
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7361
Practice Address - Country:US
Practice Address - Phone:757-694-4723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014637101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health