Provider Demographics
NPI:1639669948
Name:STATEN, BRIDGET HOLLIS (PHD, LPC, CRC)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:HOLLIS
Last Name:STATEN
Suffix:
Gender:F
Credentials:PHD, LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 MIDDLETON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4783
Mailing Address - Country:US
Mailing Address - Phone:803-534-4160
Mailing Address - Fax:803-997-2364
Practice Address - Street 1:1031 MIDDLETON ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4783
Practice Address - Country:US
Practice Address - Phone:803-534-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6569101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC12181Medicaid