Provider Demographics
NPI:1730246505
Name:BRIDGE, CLARISSA M (LCSW)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:M
Last Name:BRIDGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7131 DUMBARTON PL
Mailing Address - Street 2:
Mailing Address - City:BETHEL PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15102-3717
Mailing Address - Country:US
Mailing Address - Phone:412-831-3344
Mailing Address - Fax:
Practice Address - Street 1:4701 BAPTIST RD
Practice Address - Street 2:208A
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15227-1117
Practice Address - Country:US
Practice Address - Phone:412-882-9929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW006267L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA650691LETMedicare ID - Type Unspecified
PA650691Medicare UPIN