Provider Demographics
NPI:1114707700
Name:BRIDGE TO BRILLIANCE THERAPY LLC
Entity Type:Organization
Organization Name:BRIDGE TO BRILLIANCE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANISA
Authorized Official - Middle Name:MOHAMED
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-987-3455
Mailing Address - Street 1:7764 OAKRIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-5509
Mailing Address - Country:US
Mailing Address - Phone:612-987-3455
Mailing Address - Fax:
Practice Address - Street 1:13740 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4003
Practice Address - Country:US
Practice Address - Phone:612-987-3455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1093450918Medicaid