Provider Demographics
NPI:1518157288
Name:BRIDGES, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BRIDGES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:SKYFOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92385-0578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28545 HIWAY 18
Practice Address - Street 2:
Practice Address - City:SKYFOREST
Practice Address - State:CA
Practice Address - Zip Code:92385-0578
Practice Address - Country:US
Practice Address - Phone:909-336-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-B0704051531101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5810OtherSIMON