Healthcare Provider Details

I. General information

NPI: 1275914822
Provider Name (Legal Business Name): BUILDING BRIDGES THERAPEUTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12523 WOODCOCK LN
OAK HILL VA
20171-2502
US

IV. Provider business mailing address

12523 WOODCOCK LN
OAK HILL VA
20171-2502
US

V. Phone/Fax

Practice location:
  • Phone: 703-507-9992
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0133000345
License Number StateVA

VIII. Authorized Official

Name: MR. MARK WILLER
Title or Position: OWNER
Credential: M.ED., BCBA, LBA
Phone: 703-507-9992