=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265158323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGES INDIVIDUAL & FAMILY COUNSELING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2022
-----------------------------------------------------
Last Update Date | 10/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 527 E ROWLAND ST STE 112
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91723-3230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-598-3379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 527 E ROWLAND ST STE 112
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91723-3230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-598-3379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | ROBERTA THOMAS
-----------------------------------------------------
Credential | MA, LMFT
-----------------------------------------------------
Telephone | 626-598-3379
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------