Healthcare Provider Details

I. General information

NPI: 1124552088
Provider Name (Legal Business Name): THE BRIDGE OF GEORGIA SCHOOL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BLAINE ST
MONROE GA
30655-2403
US

IV. Provider business mailing address

109 BLAINE ST PO BOX 542
MONROE GA
30655-2403
US

V. Phone/Fax

Practice location:
  • Phone: 770-406-6111
  • Fax: 678-635-8709
Mailing address:
  • Phone: 770-406-6111
  • Fax: 678-635-8709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMILA EMBRY BURT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 770-406-6111