Provider Demographics
NPI:1568017374
Name:THE BRIDGE AUTISM CLINIC LLC
Entity Type:Organization
Organization Name:THE BRIDGE AUTISM CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-493-8412
Mailing Address - Street 1:690 CLEVELAND AVE S # 100
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:690 CLEVELAND AVE SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116
Practice Address - Country:US
Practice Address - Phone:612-216-4647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE BRIDGE AUTISM CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-08
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health