Provider Demographics
NPI:1578635629
Name:ANGEL BRIDGE, INC
Entity Type:Organization
Organization Name:ANGEL BRIDGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY JAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON-COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-371-1679
Mailing Address - Street 1:1414 E THOUSAND OAKS BLVD
Mailing Address - Street 2:#103
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4401
Mailing Address - Country:US
Mailing Address - Phone:805-371-1679
Mailing Address - Fax:
Practice Address - Street 1:1414 E THOUSAND OAKS BLVD
Practice Address - Street 2:#103
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-4401
Practice Address - Country:US
Practice Address - Phone:805-371-1679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMA14528106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty