Provider Demographics
NPI:1982489191
Name:BRIDGEWATER, ALISHIA
Entity Type:Individual
Prefix:
First Name:ALISHIA
Middle Name:
Last Name:BRIDGEWATER
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 1:1414 CHESTERPOINT DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-2568
Mailing Address - Country:US
Mailing Address - Phone:318-341-2940
Mailing Address - Fax:
Practice Address - Street 1:1414 CHESTERPOINT DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-2568
Practice Address - Country:US
Practice Address - Phone:318-341-2940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84973133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered