Provider Demographics
NPI:1083069850
Name:BRIDGE VISION LICENSED CLINICAL SOCIAL WORKER
Entity Type:Organization
Organization Name:BRIDGE VISION LICENSED CLINICAL SOCIAL WORKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:NOMSA
Authorized Official - Last Name:CHALI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LCSW
Authorized Official - Phone:909-936-3888
Mailing Address - Street 1:255 N D ST
Mailing Address - Street 2:SUITE 401H
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401
Mailing Address - Country:US
Mailing Address - Phone:909-936-3888
Mailing Address - Fax:909-635-6173
Practice Address - Street 1:357 W 2ND ST STE 3
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1803
Practice Address - Country:US
Practice Address - Phone:909-936-3888
Practice Address - Fax:909-635-6173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-29
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW29187251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health