Provider Demographics
NPI:1417714122
Name:ISHAM, BRIDGET
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:ISHAM
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 1:6520 CRYSTAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:CA
Mailing Address - Zip Code:95623-4803
Mailing Address - Country:US
Mailing Address - Phone:916-334-5437
Mailing Address - Fax:
Practice Address - Street 1:5101 GARDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633-9261
Practice Address - Country:US
Practice Address - Phone:530-334-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool