=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255123147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGE BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2025
-----------------------------------------------------
Last Update Date | 09/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 324 E BROAD STREET SUITE 109B
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-678-0038
-----------------------------------------------------
Fax | 770-678-0038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 517
-----------------------------------------------------
City | LOCUST GROVE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30248-0517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-678-0038
-----------------------------------------------------
Fax | 770-796-7726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO AND OWNER
-----------------------------------------------------
Name | EBUNOLUWA MIKIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-917-5484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------