Provider Demographics
NPI:1669468609
Name:BRIDGEWATER, MAX (MSW)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:BRIDGEWATER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 HICKMAN RD
Mailing Address - Street 2:BROADLAWNS MEDICAL CENTER
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1505
Mailing Address - Country:US
Mailing Address - Phone:515-282-2319
Mailing Address - Fax:515-282-3234
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:BROADLAWNS MEDICAL CENTER
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1505
Practice Address - Country:US
Practice Address - Phone:515-282-2319
Practice Address - Fax:515-282-3234
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01712104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker