Basic Information
| Provider Information | |||||||||
| NPI: | 1760808570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIDGES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MYERS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRIDGES | ||||||||
| OtherFirstName: | MARY MOLLY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2487 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290208009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126552323 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 125 ALPINE CIR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292236385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793548 | ||||||||
| FaxNumber: | 8037797065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2014 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6409 | SC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 6409 | SC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LPC008437 | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC008437 | GA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 6409 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.