MEDICARE: BRIDGMAN PSYCHOLOGICAL SERVICES, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC28928	CA
2	103T00000X	Psychologist	PSY14510	CA

General Provider Information

NPI Number	:	1386811776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGMAN PSYCHOLOGICAL SERVICES, P.C.

Provider Business Mailing Address
First Line	:	22792 CENTRE DR STE 290
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-6304
Country	:	US
Telephone Number	:	949-707-6633
Fax Number	:	949-770-5433

Provider Business Practice Location Address
First Line	:	22792 CENTRE DR STE 290
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-6304
Country	:	US
Telephone Number	:	949-707-6633
Fax Number	:	949-770-5433

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LAIRD BRIDGMAN
Credential	:	PSY.D.
Telephone Number	:	949-707-6633

Provider Enumeration Date	:	05/14/2008
Last Update Date	:	05/14/2008

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