Provider Demographics
NPI:1396213146
Name:SORRELLS, BRIDGETTE
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:
Last Name:SORRELLS
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 1:3976 BROOKSTONE PL APT 16
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-7831
Mailing Address - Country:US
Mailing Address - Phone:810-662-2275
Mailing Address - Fax:
Practice Address - Street 1:3976 BROOKSTONE PL APT 16
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-7831
Practice Address - Country:US
Practice Address - Phone:810-662-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0093056281Medicaid