=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386471605
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REPAIRING THE BRIDGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2024
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20740 N MADISON DR
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-8437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-701-4575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20740 N MADISON DR
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-8437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-701-4575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | SHEILA REED
-----------------------------------------------------
Credential | LASAC, TIC
-----------------------------------------------------
Telephone | 520-701-4575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------