=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497477954
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGES ACADEMY AUSTIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2022
-----------------------------------------------------
Last Update Date | 09/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 N QUINLAN PARK RD STE 250
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78732-6088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-506-1980
-----------------------------------------------------
Fax | 512-387-9734
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 N QUINLAN PARK RD STE 250
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78732-6088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-506-1980
-----------------------------------------------------
Fax | 512-387-9734
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | ALEXANDRA ELLIOT
-----------------------------------------------------
Credential | PHD, LP
-----------------------------------------------------
Telephone | 512-506-1980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------