Provider Demographics
NPI:1578823480
Name:MOSS, BRIDGET HOLYFIELD
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:HOLYFIELD
Last Name:MOSS
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 1:544 MULBERRY ST STE 107
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8249
Mailing Address - Country:US
Mailing Address - Phone:478-284-9634
Mailing Address - Fax:478-988-8796
Practice Address - Street 1:544 MULBERRY ST STE 107
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8249
Practice Address - Country:US
Practice Address - Phone:478-284-9634
Practice Address - Fax:478-988-8796
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004546101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional