=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457707507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGES TO HOPE COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2016
-----------------------------------------------------
Last Update Date | 06/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 327 BROADWAY AVE STE 16
-----------------------------------------------------
City | YANKTON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57078-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-665-4488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 327 BROADWAY AVE STE 16
-----------------------------------------------------
City | YANKTON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57078-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-665-4488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERRY L. WEBBER
-----------------------------------------------------
Credential | LCSW-PIP
-----------------------------------------------------
Telephone | 605-665-4488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3088
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------