Healthcare Provider Details

I. General information

NPI: 1063217487
Provider Name (Legal Business Name): BEACON BRIDGE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2738 WINNETKA AVE N STE 200B
NEW HOPE MN
55427-2850
US

IV. Provider business mailing address

1808 UNIVERSITY AVE NE APT 113
MINNEAPOLIS MN
55418-4315
US

V. Phone/Fax

Practice location:
  • Phone: 612-438-5540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NAJMA OMAR
Title or Position: OWNER
Credential:
Phone: 612-800-4925