MEDICARE: BRIDGE THE GAP COUNSELING 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1467055095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGE THE GAP COUNSELING LLC

Provider Business Mailing Address
First Line	:	6051 DAWN VIEW LN
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-1675
Country	:	US
Telephone Number	:	702-415-4079
Fax Number	:

Provider Business Practice Location Address
First Line	:	6051 DAWN VIEW LN
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-1675
Country	:	US
Telephone Number	:	702-415-4079
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	QUINCY SANDERS
Credential	:	MFT-INTERN
Telephone Number	:	702-415-4079

Provider Enumeration Date	:	11/17/2020
Last Update Date	:	11/17/2020

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