Healthcare Provider Details

I. General information

NPI: 1457826919
Provider Name (Legal Business Name): BRIDGET KATHLEEN RUSSELL HANLON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 WILDLIGHT AVE APT 206
YULEE FL
32097-0252
US

IV. Provider business mailing address

621 WILDLIGHT AVE APT 206
YULEE FL
32097-0252
US

V. Phone/Fax

Practice location:
  • Phone: 310-500-0677
  • Fax:
Mailing address:
  • Phone: 310-500-0677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW26264
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number85186
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904018930
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: