Provider Demographics
NPI:1508906280
Name:BANDA, BRIDGET LETICIA (PSYD, MS)
Entity Type:Individual
Prefix:DR
First Name:BRIDGET
Middle Name:LETICIA
Last Name:BANDA
Suffix:
Gender:F
Credentials:PSYD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 WESTLAKE CENTER
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE STE 125B
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2456
Practice Address - Country:US
Practice Address - Phone:510-777-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2024-02-07
Deactivation Date:2024-01-29
Deactivation Code:
Reactivation Date:2024-02-01
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103TC2200X, 101YM0800X
CAPSB33631101YM0800X
CAIMF42123101YP2500X
NA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No171M00000XOther Service ProvidersCase Manager/Care Coordinator