Provider Demographics
NPI:1639050917
Name:BRIDESON-GLYNN, LISA ANN
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BRIDESON-GLYNN
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 1:55 SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06612-1209
Mailing Address - Country:US
Mailing Address - Phone:212-734-4112
Mailing Address - Fax:
Practice Address - Street 1:64B E 86TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-1009
Practice Address - Country:US
Practice Address - Phone:212-734-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007980-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist