Healthcare Provider Details

I. General information

NPI: 1679909535
Provider Name (Legal Business Name): BRIDGE BUILDING YOUTH AND FAMILY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAIN STREET
HAYSI VA
24256
US

IV. Provider business mailing address

PO BOX 366
CLINCHCO VA
24226-0366
US

V. Phone/Fax

Practice location:
  • Phone: 276-207-2249
  • Fax:
Mailing address:
  • Phone: 276-207-2249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: PROF. CHERI ANN MEADOWLARK
Title or Position: PRESIDENT
Credential: PHD
Phone: 276-207-2249