Healthcare Provider Details

I. General information

NPI: 1386471605
Provider Name (Legal Business Name): REPAIRING THE BRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20740 N MADISON DR
MARICOPA AZ
85138-8437
US

IV. Provider business mailing address

20740 N MADISON DR
MARICOPA AZ
85138-8437
US

V. Phone/Fax

Practice location:
  • Phone: 520-701-4575
  • Fax:
Mailing address:
  • Phone: 520-701-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHEILA REED
Title or Position: OWNER/THERAPIST
Credential: LASAC, TIC
Phone: 520-701-4575