Provider Demographics
NPI:1578951109
Name:BRIDGEPATH INC
Entity Type:Organization
Organization Name:BRIDGEPATH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:PRUETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMIN, LPC, HTCP/I
Authorized Official - Phone:704-651-2895
Mailing Address - Street 1:664 W HEATHERSTONE LN
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-2787
Mailing Address - Country:US
Mailing Address - Phone:704-651-2895
Mailing Address - Fax:864-574-8142
Practice Address - Street 1:3900-B PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:704-577-5862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004101YP1600X
NC4663101YP1600X
SC15106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1407831571OtherNPI
1801872445OtherNPI NUMBER
1801872445OtherNPI NUMBER
SC1336290261OtherNPI