Healthcare Provider Details

I. General information

NPI: 1881299212
Provider Name (Legal Business Name): BLISSFUL BRIDGE TO WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 ANDERSON ST
WILMINGTON NC
28401-4210
US

IV. Provider business mailing address

410 ANDERSON ST
WILMINGTON NC
28401-4210
US

V. Phone/Fax

Practice location:
  • Phone: 910-787-1282
  • 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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: AUDREY DICKEY
Title or Position: CEO
Credential: MSW, LCSWA
Phone: 910-787-1282