Healthcare Provider Details

I. General information

NPI: 1235742552
Provider Name (Legal Business Name): THE BRIDGE THERAPEUTIC & EVALUATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7360 GRACE DR
COLUMBIA MD
21044-2470
US

IV. Provider business mailing address

7311 ZEKIAH CT
BRANDYWINE MD
20613-5940
US

V. Phone/Fax

Practice location:
  • Phone: 202-731-7352
  • Fax:
Mailing address:
  • Phone: 301-938-7276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KARENA WILSON-PLATER
Title or Position: OWNER/CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 301-938-7276