Healthcare Provider Details

I. General information

NPI: 1003374794
Provider Name (Legal Business Name): BRIDGING DIFFERENCES ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 S SHINGLE RD
SHINGLE SPRINGS CA
95682-8081
US

IV. Provider business mailing address

7520 S SHINGLE RD
SHINGLE SPRINGS CA
95682-8081
US

V. Phone/Fax

Practice location:
  • Phone: 530-280-5531
  • Fax: 208-518-1286
Mailing address:
  • Phone: 916-280-5531
  • Fax: 208-518-1286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MARY OLSON
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 916-280-4678