Provider Demographics
NPI:1386097848
Name:SOUTHERN BRIDGE INC
Entity type:Organization
Organization Name:SOUTHERN BRIDGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEVA
Authorized Official - Middle Name:DANIELLE KNIGHT
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:478-283-8322
Mailing Address - Street 1:404 CORDER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-7195
Mailing Address - Country:US
Mailing Address - Phone:478-283-8322
Mailing Address - Fax:877-712-4794
Practice Address - Street 1:404 CORDER RD STE 300
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7195
Practice Address - Country:US
Practice Address - Phone:478-283-8322
Practice Address - Fax:877-712-4794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003222274AMedicaid
GA003174143AMedicaid
GA003220322AMedicaid
GA003209756AMedicaid