Provider Demographics
NPI:1235991001
Name:DAVIS, BRIDGETT
Entity Type:Individual
Prefix:
First Name:BRIDGETT
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5027 KAMENT ST
Mailing Address - Street 2:
Mailing Address - City:BAY SAINT LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-8739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2007 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-2178
Practice Address - Country:US
Practice Address - Phone:228-369-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24-323773106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician