Provider Demographics
NPI:1568822971
Name:BRIDGE BUILDERS COUNSELING AND MENTORING INC
Entity type:Organization
Organization Name:BRIDGE BUILDERS COUNSELING AND MENTORING INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERNESTINE
Authorized Official - Middle Name:KIMBERLY
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CAADC
Authorized Official - Phone:810-987-8772
Mailing Address - Street 1:1220 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5349
Mailing Address - Country:US
Mailing Address - Phone:810-987-8772
Mailing Address - Fax:810-987-8706
Practice Address - Street 1:1220 6TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5349
Practice Address - Country:US
Practice Address - Phone:810-987-8772
Practice Address - Fax:810-987-8706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010864341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154420552Medicare NSC