Healthcare Provider Details

I. General information

NPI: 1720884653
Provider Name (Legal Business Name): EMILY BRIDGEMAN ED.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 SAINT GASPAR DR W
RENSSELAER IN
47978-7361
US

IV. Provider business mailing address

1389 SAINT GASPAR DR W
RENSSELAER IN
47978-7361
US

V. Phone/Fax

Practice location:
  • Phone: 219-866-8549
  • Fax:
Mailing address:
  • Phone: 219-866-8549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number000016857
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: