Healthcare Provider Details

I. General information

NPI: 1962647685
Provider Name (Legal Business Name): BRIDGE TO AWARENESS COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W C ST
PUEBLO CO
81003-3409
US

IV. Provider business mailing address

310 W C ST
PUEBLO CO
81003-3409
US

V. Phone/Fax

Practice location:
  • Phone: 719-296-1366
  • Fax: 719-296-6825
Mailing address:
  • Phone: 719-296-1366
  • Fax: 719-296-6825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1110-02
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1110-02
License Number StateCO

VIII. Authorized Official

Name: MR. STEVE DARR
Title or Position: DIRECTOR
Credential:
Phone: 719-471-2514