Provider Demographics
NPI:1023649092
Name:FONG, BRIDGETTE MARIE
Entity type:Individual
Prefix:MRS
First Name:BRIDGETTE
Middle Name:MARIE
Last Name:FONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19380 COLLINS AVE APT 510
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2235
Mailing Address - Country:US
Mailing Address - Phone:786-253-1402
Mailing Address - Fax:
Practice Address - Street 1:8301 W MCNAB RD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-3206
Practice Address - Country:US
Practice Address - Phone:954-771-2091
Practice Address - Fax:754-205-2161
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health