MEDICARE: BRIDGE BUILDERS COUNSELING AND MENTORING INC

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	6801086434	MI

General Provider Information

NPI Number	:	1568822971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGE BUILDERS COUNSELING AND MENTORING INC

Provider Business Mailing Address
First Line	:	1220 6TH ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-5349
Country	:	US
Telephone Number	:	810-987-8772
Fax Number	:	810-987-8706

Provider Business Practice Location Address
First Line	:	1220 6TH ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-5349
Country	:	US
Telephone Number	:	810-987-8772
Fax Number	:	810-987-8706

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MRS. ERNESTINE KIMBERLY BROWN
Credential	:	LMSW, CAADC
Telephone Number	:	810-987-8772

Provider Enumeration Date	:	02/26/2016
Last Update Date	:	02/26/2016

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