MEDICARE: BRIDGE OF LIGHT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1013747120
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGE OF LIGHT LLC

Provider Business Mailing Address
First Line	:	4512 SUNNYVIEW DR APT 178
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-3163
Country	:	US
Telephone Number	:	443-991-1582
Fax Number	:

Provider Business Practice Location Address
First Line	:	9130 S WALKER AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-8508
Country	:	US
Telephone Number	:	405-463-9796
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICAL DIRECTOR
Name	:	MS. XANDER D FAISON
Credential	:	LPC
Telephone Number	:	443-991-1582

Provider Enumeration Date	:	08/05/2024
Last Update Date	:	08/05/2024

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Directions to “BRIDGE OF LIGHT LLC ” Practice Location

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