Healthcare Provider Details

I. General information

NPI: 1710392220
Provider Name (Legal Business Name): BRIDGES HABILITATION SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S KENDRICK AVE SUITE 201D
GILLETTE WY
82716-3848
US

IV. Provider business mailing address

PO BOX 1642
EVANSTON WY
82931-1642
US

V. Phone/Fax

Practice location:
  • Phone: 307-685-7105
  • Fax: 307-222-0614
Mailing address:
  • Phone: 307-789-0664
  • Fax: 307-789-1902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. DAVID M CANEN
Title or Position: CEO
Credential:
Phone: 307-789-0664