Provider Demographics
NPI:1003374794
Name:BRIDGING DIFFERENCES ABA
Entity Type:Organization
Organization Name:BRIDGING DIFFERENCES ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-280-4678
Mailing Address - Street 1:7520 S SHINGLE RD
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8081
Mailing Address - Country:US
Mailing Address - Phone:916-280-5531
Mailing Address - Fax:208-518-1286
Practice Address - Street 1:7520 S SHINGLE RD
Practice Address - Street 2:
Practice Address - City:SHINGLE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95682-8081
Practice Address - Country:US
Practice Address - Phone:530-280-5531
Practice Address - Fax:208-518-1286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285018002OtherNPPES