Healthcare Provider Details

I. General information

NPI: 1508168337
Provider Name (Legal Business Name): BRIDGING HOPE COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 BRIGHTON AVE S SUITE B
BUFFALO MN
55313-2312
US

IV. Provider business mailing address

21000 ROGERS DR SUITE 200
ROGERS MN
55374-4652
US

V. Phone/Fax

Practice location:
  • Phone: 763-291-5505
  • Fax: 763-657-0819
Mailing address:
  • Phone: 763-291-5505
  • Fax: 763-657-0819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1894
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1894
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number1894
License Number StateMN

VIII. Authorized Official

Name: HEIDI LYNN WALDOCH
Title or Position: LMFT
Credential: MA
Phone: 763-291-5505