=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790269124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGE OF HOPE LIFE TRANSFORMATIONAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2018
-----------------------------------------------------
Last Update Date | 10/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 WEST ST S STE B
-----------------------------------------------------
City | AHOSKIE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27910-3342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-862-8505
-----------------------------------------------------
Fax | 252-862-8512
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 409 QUEBEC RD
-----------------------------------------------------
City | COLERAIN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27924-9488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-862-8505
-----------------------------------------------------
Fax | 252-862-8512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LAKEISHA YVETTE WALKER
-----------------------------------------------------
Credential | LPC, CTP
-----------------------------------------------------
Telephone | 252-862-8505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------