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General NPI Number Information
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NPI Number | 1568017374
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Entity Type | Organization
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Legal Business Name | THE BRIDGE AUTISM CLINIC LLC
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Dates
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Enumeration Date | 08/08/2019
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Last Update Date | 12/10/2019
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Provider Practice Location Address
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Address Line | 690 CLEVELAND AVE SOUTH SUITE 100
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City | ST PAUL
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State | MN
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Zip | 55116
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Country | US
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Telephone | 612-216-4647
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Fax |
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Provider Business Mailing Address
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Address Line | 690 CLEVELAND AVE S # 100
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City | SAINT PAUL
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State | MN
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Zip | 55116-1319
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR CEO
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Name | MELISSA HAMILTON
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Credential |
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Telephone | 651-493-8412
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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