Basic Information
| Provider Information | |||||||||
| NPI: | 1083815674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIDGES CLUBHOUSE MENTAL HEALTH OF AMERICA SOUTH CAROLINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2021 ELM ABODE TER | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292107724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034464246 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2105 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | CAYCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290331524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037966179 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | TUCKER | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 8037960353 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | M.R.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 01858 600 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.