Basic Information
| Provider Information | |||||||||
| NPI: | 1154568392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUTHERN | ||||||||
| FirstName: | BRIDGETTE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LLMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NADEAN | ||||||||
| OtherFirstName: | BRIDGETTE | ||||||||
| OtherMiddleName: | N | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 585 JEWETT RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488548729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178338100 | ||||||||
| FaxNumber: | 5176765207 | ||||||||
| Practice Location | |||||||||
| Address1: | 2702 FLUSHING RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485044534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104245998 | ||||||||
| FaxNumber: | 8104246347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2009 | ||||||||
| LastUpdateDate: | 01/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801085378 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.