Provider Demographics
NPI:1528873502
Name:BEACON BRIDGE OF WEST VIRGINIA
Entity type:Organization
Organization Name:BEACON BRIDGE OF WEST VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUSIF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:984-282-6654
Mailing Address - Street 1:415 DUNSTAN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2390
Mailing Address - Country:US
Mailing Address - Phone:984-282-6654
Mailing Address - Fax:984-208-5220
Practice Address - Street 1:5662 BRIER CREEK RD
Practice Address - Street 2:
Practice Address - City:DAVY
Practice Address - State:WV
Practice Address - Zip Code:24828-8802
Practice Address - Country:US
Practice Address - Phone:984-282-6654
Practice Address - Fax:984-208-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health