Provider Demographics
NPI:1942743992
Name:BRIDGEWATER, MARY LOUISE (LMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:BRIDGEWATER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N NIAGARA ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4359
Mailing Address - Country:US
Mailing Address - Phone:989-401-5562
Mailing Address - Fax:
Practice Address - Street 1:1010 N NIAGARA ST STE 2
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4359
Practice Address - Country:US
Practice Address - Phone:989-401-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801012588101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health