Provider Demographics
NPI:1467604405
Name:BRIDGES 2 PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:BRIDGES 2 PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:BRIDGES 2 PSYCHOLOGICAL SERVICES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:BARROS
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:202-849-2915
Mailing Address - Street 1:639 ATLANTIC ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-3738
Mailing Address - Country:US
Mailing Address - Phone:202-849-2915
Mailing Address - Fax:202-627-5028
Practice Address - Street 1:639 ATLANTIC ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3738
Practice Address - Country:US
Practice Address - Phone:202-849-2915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04233251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD414581000Medicaid