Healthcare Provider Details

I. General information

NPI: 1932563673
Provider Name (Legal Business Name): JOHN RUSSELL BRIDGER PH.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 W UNIVERSITY AVE STE 202
FLAGSTAFF AZ
86001-2996
US

IV. Provider business mailing address

1016 W UNIVERSITY AVE STE 202
FLAGSTAFF AZ
86001-2996
US

V. Phone/Fax

Practice location:
  • Phone: 970-844-7151
  • Fax:
Mailing address:
  • Phone: 970-844-7151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0005360
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-005572
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: