Provider Demographics
NPI:1891749610
Name:BRIDGE BUILDERS PASTORAL COUNSELING AND PSYCHOTHERAPY
Entity Type:Organization
Organization Name:BRIDGE BUILDERS PASTORAL COUNSELING AND PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:910-792-9888
Mailing Address - Street 1:5919 OLEANDER DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4780
Mailing Address - Country:US
Mailing Address - Phone:910-792-9888
Mailing Address - Fax:910-792-9883
Practice Address - Street 1:5919 OLEANDER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4780
Practice Address - Country:US
Practice Address - Phone:910-792-9888
Practice Address - Fax:910-792-9883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006898Medicaid