MEDICARE: BRIDGETTE D HERREN LISW, LICDC, MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	ICDC.141066	OH
2	1041C0700X	Clinical Social Worker	I.1600705

General Provider Information

NPI Number	:	1023367679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIDGETTE D HERREN LISW, LICDC, MSW

Provider Business Mailing Address
First Line	:	5818 WILMINGTON PIKE
Second Line	:	PMB 207
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-7004
Country	:	US
Telephone Number	:	937-301-5549
Fax Number	:

Provider Business Practice Location Address
First Line	:	7133 OLD TROY PIKE
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-2658
Country	:	US
Telephone Number	:	937-301-5549
Fax Number	:	937-723-9095

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2012
Last Update Date	:	02/12/2022

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