Provider Demographics
NPI:1790129187
Name:BLEAN, BRIDGET G (MAC)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:G
Last Name:BLEAN
Suffix:
Gender:F
Credentials:MAC
Other - Prefix:
Other - First Name:BRIDGET
Other - Middle Name:G
Other - Last Name:VANDEWALLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 E WALNUT ST
Mailing Address - Street 2:SUITE 706
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4239
Mailing Address - Country:US
Mailing Address - Phone:920-437-8256
Mailing Address - Fax:920-437-1188
Practice Address - Street 1:130 E WALNUT ST
Practice Address - Street 2:SUITE 706
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4239
Practice Address - Country:US
Practice Address - Phone:920-437-8256
Practice Address - Fax:920-437-1188
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1150-WI101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor