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General NPI Number Information
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NPI Number | 1114707700
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Entity Type | Organization
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Legal Business Name | BRIDGE TO BRILLIANCE THERAPY LLC
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Dates
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Enumeration Date | 10/02/2023
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Last Update Date | 10/02/2023
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Provider Practice Location Address
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Address Line | 13740 NICOLLET AVE
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City | BURNSVILLE
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State | MN
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Zip | 55337-4003
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Country | US
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Telephone | 612-987-3455
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Fax |
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Provider Business Mailing Address
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Address Line | 7764 OAKRIDGE TRL
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City | SHAKOPEE
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State | MN
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Zip | 55379-5509
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Country | US
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Telephone | 612-987-3455
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANISA MOHAMED AHMED
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Credential |
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Telephone | 612-987-3455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State |
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