Basic Information
| Provider Information | |||||||||
| NPI: | 1659918241 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIDGE COUNSELING ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1640 ALTA DR STE 4 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024746450 | ||||||||
| FaxNumber: | 7024746463 | ||||||||
| Practice Location | |||||||||
| Address1: | 4221 MCLEOD DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891215215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024746450 | ||||||||
| FaxNumber: | 7024746463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2019 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | TAKARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7024746450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 250005387 | 05 | NV | MEDICAID |