Healthcare Provider Details

I. General information

NPI: 1699137737
Provider Name (Legal Business Name): HEALTH BRIDGE NEWPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20072 SW BIRCH ST SUITE 240
NEWPORT BEACH CA
92660-0794
US

IV. Provider business mailing address

20072 SW BIRCH ST SUITE 240
NEWPORT BEACH CA
92660-0794
US

V. Phone/Fax

Practice location:
  • Phone: 949-715-9321
  • Fax: 310-300-0306
Mailing address:
  • Phone: 949-715-9321
  • Fax: 310-300-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberND-145
License Number StateCA

VIII. Authorized Official

Name: GINA NICK CUSHMAN
Title or Position: OWNER
Credential: MD
Phone: 949-715-9321