Provider Demographics
NPI:1104198720
Name:BUSHNELL, BRIDGETT (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGETT
Middle Name:
Last Name:BUSHNELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7611 SAINT VINCENT AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-4231
Mailing Address - Country:US
Mailing Address - Phone:318-861-1671
Mailing Address - Fax:318-861-6529
Practice Address - Street 1:7611 SAINT VINCENT AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-4231
Practice Address - Country:US
Practice Address - Phone:318-861-1671
Practice Address - Fax:318-861-6529
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA77761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical