Provider Demographics
NPI:1992478077
Name:BRIDGENS, CHARMAINE
Entity type:Individual
Prefix:MRS
First Name:CHARMAINE
Middle Name:
Last Name:BRIDGENS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 FORREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-6521
Mailing Address - Country:US
Mailing Address - Phone:714-316-2932
Mailing Address - Fax:
Practice Address - Street 1:1303 SAN CARLOS AVE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2317
Practice Address - Country:US
Practice Address - Phone:650-394-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA134305106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist