=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922872886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPEUTIC BRIDGES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2023
-----------------------------------------------------
Last Update Date | 11/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 E FORT AVE APT B
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21230-4655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-515-7067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 445 E FORT AVE APT B
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21230-4655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-515-7067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO AND OWNER
-----------------------------------------------------
Name | MISS AMANDA MENKE
-----------------------------------------------------
Credential | LCSW-C, LICSW, MSW
-----------------------------------------------------
Telephone | 443-515-7067
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------