Healthcare Provider Details

I. General information

NPI: 1215531959
Provider Name (Legal Business Name): BRIDGING THE GAP EARLY INTERVENTION CENER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 JIMSON CIR SE
CONYERS GA
30013-2054
US

IV. Provider business mailing address

1042 JIMSON CIR SE
CONYERS GA
30013-2054
US

V. Phone/Fax

Practice location:
  • Phone: 470-331-5809
  • Fax:
Mailing address:
  • Phone: 470-331-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. ALLISON C. CURLING
Title or Position: EARLY INTERVENTION SPECIALIST
Credential:
Phone: 516-499-0499