Provider Demographics
NPI:1710547245
Name:THE BRIDGE COUNSELING, LLC
Entity Type:Organization
Organization Name:THE BRIDGE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:KERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-410-4866
Mailing Address - Street 1:2818 SUNRAY LOOP
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6700
Mailing Address - Country:US
Mailing Address - Phone:208-720-2969
Mailing Address - Fax:
Practice Address - Street 1:493 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-7441
Practice Address - Country:US
Practice Address - Phone:208-410-4866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1811349129OtherNPI