Healthcare Provider Details

I. General information

NPI: 1891749610
Provider Name (Legal Business Name): BRIDGE BUILDERS PASTORAL COUNSELING AND PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5919 OLEANDER DR SUITE 104
WILMINGTON NC
28403-4780
US

IV. Provider business mailing address

5919 OLEANDER DR SUITE 104
WILMINGTON NC
28403-4780
US

V. Phone/Fax

Practice location:
  • Phone: 910-792-9888
  • Fax: 910-792-9883
Mailing address:
  • Phone: 910-792-9888
  • Fax: 910-792-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS M OWEN
Title or Position: PRESIDENT
Credential: LPC
Phone: 910-792-9888