Provider Demographics
NPI:1720373954
Name:ATALLAH, BRIDGETTE COLWELL (MA)
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:COLWELL
Last Name:ATALLAH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:BRIDGETTE
Other - Middle Name:SUSAN
Other - Last Name:COLWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:629 CAMINO DE LOS MARES
Mailing Address - Street 2:STE 207A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2832
Mailing Address - Country:US
Mailing Address - Phone:949-228-9080
Mailing Address - Fax:
Practice Address - Street 1:629 CAMINO DE LOS MARES
Practice Address - Street 2:STE 207A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2832
Practice Address - Country:US
Practice Address - Phone:949-228-9080
Practice Address - Fax:844-602-4623
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CAPSY 26225103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional