Provider Demographics
NPI:1538664800
Name:BRYDGES, SAMANTHA PENELOPE
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:PENELOPE
Last Name:BRYDGES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:PENELOPE
Other - Last Name:RICHARDSON/FIETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1423 FIELD STREET
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214
Mailing Address - Country:US
Mailing Address - Phone:313-347-2070
Mailing Address - Fax:313-924-0350
Practice Address - Street 1:1423 FIELD STREET
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2141
Practice Address - Country:US
Practice Address - Phone:313-924-7860
Practice Address - Fax:313-924-0350
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical