Healthcare Provider Details

I. General information

NPI: 1194376988
Provider Name (Legal Business Name): BRIDGE STREET COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 TELLURIDE ST UNIT 600
BRIGHTON CO
80601-4366
US

IV. Provider business mailing address

203 TELLURIDE ST UNIT 600
BRIGHTON CO
80601-4366
US

V. Phone/Fax

Practice location:
  • Phone: 720-263-2256
  • Fax: 303-659-8803
Mailing address:
  • Phone: 720-263-2256
  • Fax: 303-659-8803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARLES DESHAZER
Title or Position: OWNER
Credential: LMFT, LAC
Phone: 720-263-2256