Provider Demographics
NPI:1376778894
Name:NOLAN, BRIDGET B
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:B
Last Name:NOLAN
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 1:5930 LOVERS LN STE B
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5930 LOVERS LN STE B
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1688
Practice Address - Country:US
Practice Address - Phone:269-366-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013814103T00000X
MI6401010951101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist