Provider Demographics
NPI:1235653668
Name:BRIDGEMAN, BRANDON (LMFT)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:BRIDGEMAN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10209 E 34TH LN
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-4938
Mailing Address - Country:US
Mailing Address - Phone:410-585-5506
Mailing Address - Fax:
Practice Address - Street 1:409 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108
Practice Address - Country:US
Practice Address - Phone:619-346-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100022101Y00000X
CAIMF100022106H00000X
CALMFT124014106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF100022Medicaid