Provider Demographics
NPI:1013491273
Name:MYKE, BRIDGET (CTRS)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:MYKE
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2925 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4825
Practice Address - Country:US
Practice Address - Phone:313-396-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-23
Last Update Date:2018-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225800000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator