Provider Demographics
NPI:1710559455
Name:BRIDGMAN, GORDANA
Entity Type:Individual
Prefix:
First Name:GORDANA
Middle Name:
Last Name:BRIDGMAN
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 1:705 BELAUTO CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45430-1778
Mailing Address - Country:US
Mailing Address - Phone:937-416-8902
Mailing Address - Fax:
Practice Address - Street 1:705 BELAUTO CT
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45430-1778
Practice Address - Country:US
Practice Address - Phone:937-416-8902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176080101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH176080OtherCDCA