Healthcare Provider Details

I. General information

NPI: 1508278136
Provider Name (Legal Business Name): BUILDING A BRIDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MEDICAL DR
DOTHAN AL
36303-6903
US

IV. Provider business mailing address

101 MEDICAL DR
DOTHAN AL
36303-6903
US

V. Phone/Fax

Practice location:
  • Phone: 334-702-7222
  • Fax: 334-702-1944
Mailing address:
  • Phone: 334-702-7222
  • Fax: 334-702-1944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3655C
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1043519739
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name: MRS. DENISE CLEVELAND
Title or Position: PRESIDENT
Credential: LCSW
Phone: 334-702-7222