Provider Demographics
NPI:1366818577
Name:WIECKOWSKI, BRIDGET MARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIDGET
Middle Name:MARY
Last Name:WIECKOWSKI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 S WINCHESTER BLVD STE J205
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3918
Mailing Address - Country:US
Mailing Address - Phone:408-680-4114
Mailing Address - Fax:
Practice Address - Street 1:1101 S WINCHESTER BLVD STE J205
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3918
Practice Address - Country:US
Practice Address - Phone:408-680-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
CAPSY31996103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program