MEDICARE: GENERATIONAL BRIDGES NEUROPSYCHOLOGICAL SERVICES PLLC

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	103G00000X	Clinical Neuropsychologist

General Provider Information

NPI Number	:	1467088062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENERATIONAL BRIDGES NEUROPSYCHOLOGICAL SERVICES PLLC

Provider Business Mailing Address
First Line	:	1515 E MISSOURI DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 E MISSOURI AVE STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2443
Country	:	US
Telephone Number	:	623-322-9936
Fax Number	:	623-218-1337

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEPHANIE MIDDAUGH
Credential	:	PSYD
Telephone Number	:	623-322-9936

Provider Enumeration Date	:	03/16/2020
Last Update Date	:	01/15/2021

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