Healthcare Provider Details

I. General information

NPI: 1467925768
Provider Name (Legal Business Name): BRIDGE TO HOPE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 SUSAN DR. STE. C
NORMAL IL
61761-6285
US

IV. Provider business mailing address

321 SUSAN DR. STE. C
NORMAL IL
61761-6285
US

V. Phone/Fax

Practice location:
  • Phone: 309-455-5703
  • Fax: 309-204-5456
Mailing address:
  • Phone: 309-455-5703
  • Fax: 309-204-5456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY MOUSTOUKKIS
Title or Position: OWNER
Credential: LCSW
Phone: 309-455-5703