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General NPI Number Information
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NPI Number | 1144793118
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Entity Type | Organization
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Legal Business Name | BRIDGE TO RESOLUTION COUNSELING AND REHABILITATION
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Dates
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Enumeration Date | 01/02/2019
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Last Update Date | 03/20/2019
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Provider Practice Location Address
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Address Line | 5991 CHESTER AVE STE 211
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2245
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Country | US
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Telephone | 904-566-0200
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Fax |
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Provider Business Mailing Address
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Address Line | 1164 E 17TH ST
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City | JACKSONVILLE
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State | FL
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Zip | 32206-3215
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Country | US
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Telephone | 904-566-0200
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | TIFFANY S WELLS
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Credential | LMHCI
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Telephone | 904-566-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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