Provider Demographics
NPI:1285223081
Name:BRIDGE, MARISA L
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:L
Last Name:BRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:L
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2300 VENLOE DR
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1745
Mailing Address - Country:US
Mailing Address - Phone:330-559-2023
Mailing Address - Fax:
Practice Address - Street 1:165 E PARK AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2352
Practice Address - Country:US
Practice Address - Phone:330-544-8005
Practice Address - Fax:330-544-9379
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2404514101YM0800X
OHCDCA.176188101YA0400X
OHC.2204107101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)