Provider Demographics
NPI:1821214511
Name:WILSON, BRIDGET A (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:BRIDGET
Other - Middle Name:
Other - Last Name:GAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CF-SLP
Mailing Address - Street 1:130 BAY RIDGE PKWY
Mailing Address - Street 2:APT 2N
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-2306
Mailing Address - Country:US
Mailing Address - Phone:347-393-2922
Mailing Address - Fax:
Practice Address - Street 1:160 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1103
Practice Address - Country:US
Practice Address - Phone:718-436-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1943874235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist