Organization
BRIDGE TO BRILLIANCE THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANISA MOHAMED AHMED (OWNER)
(612) 987-3455
Entity
Organization
Contact information
Practice address
13740 NICOLLET AVE, BURNSVILLE, MN 55337-4003
(612) 987-3455
Mailing address
7764 OAKRIDGE TRL, SHAKOPEE, MN 55379-5509
(612) 987-3455
Taxonomy
Speciality
Code
Description
License number
State
252Y00000X
Early Intervention Provider Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1093450918
—
MN
Enumeration date
10/02/2023
Last updated
10/02/2023
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