Basic Information
| Provider Information | |||||||||
| NPI: | 1043627987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIDGING COMMUNITY WITH HEALTHCARE, LLC | ||||||||
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| OtherOrganizationName: | BROOKHAVEN HEALTH AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 W CONGRESS ST | ||||||||
| Address2: | 1007 W. CONGRES STREET - MAILING ADDRESS | ||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018339388 | ||||||||
| FaxNumber: | 6018339495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 W CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018339388 | ||||||||
| FaxNumber: | 6018339495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2014 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6018233221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DNP | ||||||||
| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QP2300X | R880146 | MS | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 314000000X | R880146 | MS | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.