Provider Demographics
NPI:1457122962
Name:BRIDGE, GUTHRIE (CMT)
Entity Type:Individual
Prefix:
First Name:GUTHRIE
Middle Name:
Last Name:BRIDGE
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 811
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-0811
Mailing Address - Country:US
Mailing Address - Phone:631-742-7929
Mailing Address - Fax:
Practice Address - Street 1:2635 CLEVELAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2981
Practice Address - Country:US
Practice Address - Phone:707-239-9224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92494225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist