Healthcare Provider Details

I. General information

NPI: 1386570547
Provider Name (Legal Business Name): SHAYLA BRIDGEWATER LMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8972 W 125 N
ETNA GREEN IN
46524-9521
US

IV. Provider business mailing address

8972 W 125 N
ETNA GREEN IN
46524-9521
US

V. Phone/Fax

Practice location:
  • Phone: 574-201-7495
  • Fax:
Mailing address:
  • Phone: 574-201-7495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number88003360A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: