Provider Demographics
NPI:1013961168
Name:GONNEVILLE, BRIDGET LYNN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:BRIDGET
Middle Name:LYNN
Last Name:GONNEVILLE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 CLIFFORD ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-5330
Mailing Address - Country:US
Mailing Address - Phone:508-676-5708
Mailing Address - Fax:508-676-1948
Practice Address - Street 1:66 TROY ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3023
Practice Address - Country:US
Practice Address - Phone:508-676-5708
Practice Address - Fax:508-676-1948
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1105661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP22309Medicare ID - Type Unspecified