Provider Demographics
NPI:1336886027
Name:WILEY, BRIDGETT PRINCESS
Entity Type:Individual
Prefix:
First Name:BRIDGETT
Middle Name:PRINCESS
Last Name:WILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 SKATE RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3822
Mailing Address - Country:US
Mailing Address - Phone:904-535-4154
Mailing Address - Fax:
Practice Address - Street 1:6639 SOUTHPOINT PKWY STE 108
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8042
Practice Address - Country:US
Practice Address - Phone:904-438-7640
Practice Address - Fax:904-438-7656
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty