Healthcare Provider Details

I. General information

NPI: 1568017374
Provider Name (Legal Business Name): THE BRIDGE AUTISM CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 CLEVELAND AVE SOUTH SUITE 100
ST PAUL MN
55116
US

IV. Provider business mailing address

690 CLEVELAND AVE S # 100
SAINT PAUL MN
55116-1319
US

V. Phone/Fax

Practice location:
  • Phone: 612-216-4647
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA HAMILTON
Title or Position: DIRECTOR CEO
Credential:
Phone: 651-493-8412