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General NPI Number Information
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NPI Number | 1073966123
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Entity Type | Organization
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Legal Business Name | EMERALD BRIDGES FAMILY THERAPY, LLC
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Dates
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Enumeration Date | 07/13/2016
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Last Update Date | 07/13/2016
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Provider Practice Location Address
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Address Line | 2349 JAMESTOWN AVE SUITE 5
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City | INDEPENDENCE
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State | IA
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Zip | 50644-9709
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Country | US
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Telephone | 563-579-1181
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Fax | 319-332-1241
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Provider Business Mailing Address
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Address Line | 914 OREGON ST
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City | WATERLOO
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State | IA
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Zip | 50702-2509
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Country | US
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Telephone | 563-579-1181
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH THERAPIST
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Name | TARA NISSEN
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Credential | LISW
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Telephone | 563-579-1181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 007613
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License Number State | IA
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