Provider Demographics
NPI:1467088062
Name:GENERATIONAL BRIDGES NEUROPSYCHOLOGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:GENERATIONAL BRIDGES NEUROPSYCHOLOGICAL SERVICES PLLC
Other - Org Name:GENERATIONAL BRIDGES NEUROPSYCHOLOGICAL SERVICES PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:623-322-9936
Mailing Address - Street 1:1515 E MISSOURI AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2443
Mailing Address - Country:US
Mailing Address - Phone:623-322-9936
Mailing Address - Fax:623-218-1337
Practice Address - Street 1:1515 E MISSOURI AVE STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2443
Practice Address - Country:US
Practice Address - Phone:623-322-9936
Practice Address - Fax:623-218-1337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-16
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty