Healthcare Provider Details

I. General information

NPI: 1902786957
Provider Name (Legal Business Name): MARIAM NICOLE BRIDGE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2182 SKYS END DR APT S3
WINDSOR CO
80550-5090
US

IV. Provider business mailing address

PO BOX 334
WINDSOR CO
80550-0334
US

V. Phone/Fax

Practice location:
  • Phone: 970-612-8228
  • Fax:
Mailing address:
  • Phone: 970-612-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0023720
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: