Healthcare Provider Details

I. General information

NPI: 1942988852
Provider Name (Legal Business Name): 49TH BRIDGE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 N STEPHANIE ST STE G288
HENDERSON NV
89074-8117
US

IV. Provider business mailing address

213 N STEPHANIE ST STE G288
HENDERSON NV
89074-8117
US

V. Phone/Fax

Practice location:
  • Phone: 907-771-0536
  • Fax: 888-467-5306
Mailing address:
  • Phone: 907-771-0536
  • Fax: 888-467-5306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: THERESA M RONCO
Title or Position: MANAGER
Credential:
Phone: 907-748-9890