Basic Information
| Provider Information | |||||||||
| NPI: | 1083069850 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDGE VISION LICENSED CLINICAL SOCIAL WORKER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 N D ST | ||||||||
| Address2: | SUITE 401H | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099363888 | ||||||||
| FaxNumber: | 9096356173 | ||||||||
| Practice Location | |||||||||
| Address1: | 357 W 2ND ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924011803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099363888 | ||||||||
| FaxNumber: | 9096356173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2016 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | CHALI | ||||||||
| AuthorizedOfficialFirstName: | COLLEEN | ||||||||
| AuthorizedOfficialMiddleName: | NOMSA | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9099363888 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD, LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LCSW29187 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.