Healthcare Provider Details

I. General information

NPI: 1386811776
Provider Name (Legal Business Name): BRIDGMAN PSYCHOLOGICAL SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22792 CENTRE DR STE 290
LAKE FOREST CA
92630-6304
US

IV. Provider business mailing address

22792 CENTRE DR STE 290
LAKE FOREST CA
92630-6304
US

V. Phone/Fax

Practice location:
  • Phone: 949-707-6633
  • Fax: 949-770-5433
Mailing address:
  • Phone: 949-707-6633
  • Fax: 949-770-5433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY14510
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC28928
License Number StateCA

VIII. Authorized Official

Name: DR. LAIRD BRIDGMAN
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 949-707-6633