=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871386532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAINBRIDGE CONNECT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2025
-----------------------------------------------------
Last Update Date | 05/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3616 BLUE STEM CT
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23435-0077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-434-8513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3616 BLUE STEM CT
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23435-0077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-434-8513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LISA GARRETT
-----------------------------------------------------
Credential | CCC-SLP
-----------------------------------------------------
Telephone | 757-434-8513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------