Provider Demographics
NPI:1912611476
Name:BRIDGEMAN, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:BRIDGEMAN
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 1:2904 LYNDALE AVE S APT 332
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4886
Mailing Address - Country:US
Mailing Address - Phone:612-597-4939
Mailing Address - Fax:
Practice Address - Street 1:5555 BOONE AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3636
Practice Address - Country:US
Practice Address - Phone:651-774-0011
Practice Address - Fax:651-774-0606
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN290781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical