Healthcare Provider Details

I. General information

NPI: 1487021788
Provider Name (Legal Business Name): THEBRIDGE FAMILY THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2015
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N 18TH ST
MONROE LA
71201-4432
US

IV. Provider business mailing address

1900 N 18TH ST
MONROE LA
71201-4432
US

V. Phone/Fax

Practice location:
  • Phone: 318-600-6838
  • Fax:
Mailing address:
  • Phone: 318-600-6838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY M JOHNSON
Title or Position: AGENCY MANAGER
Credential:
Phone: 318-600-6838