=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568822971
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGE BUILDERS COUNSELING AND MENTORING INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2016
-----------------------------------------------------
Last Update Date | 02/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 6TH ST
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-5349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-987-8772
-----------------------------------------------------
Fax | 810-987-8706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1220 6TH ST
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-5349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-987-8772
-----------------------------------------------------
Fax | 810-987-8706
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MRS. ERNESTINE KIMBERLY BROWN
-----------------------------------------------------
Credential | LMSW, CAADC
-----------------------------------------------------
Telephone | 810-987-8772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801086434
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------