Provider Demographics
NPI:1912268467
Name:TOWER BRIDGE DEVELOPMENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:TOWER BRIDGE DEVELOPMENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKERSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-513-8321
Mailing Address - Street 1:9484 S EASTERN AVE
Mailing Address - Street 2:SUITE 67
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-3987
Mailing Address - Country:US
Mailing Address - Phone:702-513-8321
Mailing Address - Fax:
Practice Address - Street 1:9484 S EASTERN AVE
Practice Address - Street 2:SUITE 67
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-3987
Practice Address - Country:US
Practice Address - Phone:702-513-8321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1679847040Medicaid
NV1750642310Medicaid
NV1053417345Medicaid
NV1487953915Medicaid
NV1619968021Medicaid
NV1912272527Medicaid