Provider Demographics
NPI:1386764488
Name:BRIDGE, KEVEN S (MSW)
Entity type:Individual
Prefix:MS
First Name:KEVEN
Middle Name:S
Last Name:BRIDGE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-4923
Mailing Address - Country:US
Mailing Address - Phone:631-287-3114
Mailing Address - Fax:631-287-4316
Practice Address - Street 1:137 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4923
Practice Address - Country:US
Practice Address - Phone:631-287-3114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO24115-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical