Provider Demographics
NPI:1265960850
Name:BRIDGEWATER, STEPHEN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:BRIDGEWATER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30826 LINDER RD
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-8507
Mailing Address - Country:US
Mailing Address - Phone:225-665-7878
Mailing Address - Fax:225-665-7856
Practice Address - Street 1:30826 LINDER RD
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-8507
Practice Address - Country:US
Practice Address - Phone:225-665-7878
Practice Address - Fax:225-665-7856
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1548839Medicaid