Provider Demographics
NPI:1962647685
Name:BRIDGE TO AWARENESS COUNSELING CENTER
Entity Type:Organization
Organization Name:BRIDGE TO AWARENESS COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:DARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-471-2514
Mailing Address - Street 1:310 W C ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3409
Mailing Address - Country:US
Mailing Address - Phone:719-296-1366
Mailing Address - Fax:719-296-6825
Practice Address - Street 1:310 W C ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3409
Practice Address - Country:US
Practice Address - Phone:719-296-1366
Practice Address - Fax:719-296-6825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1110-02101YA0400X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04433262Medicaid