MEDICARE: BRIDGE TO HOPE 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1467925768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGE TO HOPE COUNSELING, LLC

Provider Business Mailing Address
First Line	:	321 SUSAN DR.
Second Line	:	STE. C
City	:	NORMAL
State	:	IL
Zip	:	61761-6285
Country	:	US
Telephone Number	:	309-455-5703
Fax Number	:	309-204-5456

Provider Business Practice Location Address
First Line	:	321 SUSAN DR.
Second Line	:	STE. C
City	:	NORMAL
State	:	IL
Zip	:	61761-6285
Country	:	US
Telephone Number	:	309-455-5703
Fax Number	:	309-204-5456

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY MOUSTOUKKIS
Credential	:	LCSW
Telephone Number	:	309-455-5703

Provider Enumeration Date	:	01/09/2019
Last Update Date	:	06/18/2026

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