Healthcare Provider Details

I. General information

NPI: 1366226987
Provider Name (Legal Business Name): CROSSBRIDGE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 EDGEWATER CORPORATE PKWY STE 101
INDIAN LAND SC
29707-4526
US

IV. Provider business mailing address

9400 AVERY LILAC LN
INDIAN LAND SC
29707-6921
US

V. Phone/Fax

Practice location:
  • Phone: 814-882-5400
  • Fax: 866-604-5401
Mailing address:
  • Phone: 814-882-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RON MILLER
Title or Position: PRESIDENT
Credential: PH.D
Phone: 814-882-5400