Provider Demographics
NPI:1063448694
Name:LEICESTER, BRIDGET (LICSW)
Entity Type:Individual
Prefix:MS
First Name:BRIDGET
Middle Name:
Last Name:LEICESTER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:PROCTORSVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05153-0000
Mailing Address - Country:US
Mailing Address - Phone:802-226-7450
Mailing Address - Fax:
Practice Address - Street 1:90 MAHONEY AVE
Practice Address - Street 2:PSYCHIATRY & PSYCHOTHERAPY ASSOCS
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-0000
Practice Address - Country:US
Practice Address - Phone:802-775-2581
Practice Address - Fax:802-775-3395
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00009281041C0700X
NYR042998-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562610Medicaid
VT59551OtherBL CR BL SH OF VT
VT1009403Medicaid
VT412173OtherMVP
VT1009403Medicaid
N7B021Medicare ID - Type Unspecified