Provider Demographics
NPI:1134677008
Name:LESURE, BRIDGET CHARESE (LMSW, LADAC, ICADC,)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:CHARESE
Last Name:LESURE
Suffix:
Gender:F
Credentials:LMSW, LADAC, ICADC,
Other - Prefix:
Other - First Name:BRIDGET
Other - Middle Name:CHARESE
Other - Last Name:WICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW, LADAC, ICADC,
Mailing Address - Street 1:84 TRIBBLE RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-8600
Mailing Address - Country:US
Mailing Address - Phone:662-629-0516
Mailing Address - Fax:
Practice Address - Street 1:66 TRIBBLE RD
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-8600
Practice Address - Country:US
Practice Address - Phone:662-629-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCH3925101YM0800X
MSM11185104100000X
TN15729104100000X
TN1698101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST4C-AGENCYMedicaid