MEDICARE: A BRIDGE BACK, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1578387544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A BRIDGE BACK, INC.

Provider Business Mailing Address
First Line	:	1655 N ARLINGTON HEIGHTS RD STE 305E
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-3978
Country	:	US
Telephone Number	:	844-427-6739
Fax Number	:

Provider Business Practice Location Address
First Line	:	1655 N ARLINGTON HEIGHTS RD STE 305E
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-3978
Country	:	US
Telephone Number	:	844-427-6739
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DIMITRY LIKTEREV
Credential	:
Telephone Number	:	847-414-3517

Provider Enumeration Date	:	11/14/2024
Last Update Date	:	02/12/2026

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Directions to “A BRIDGE BACK, INC. ” Practice Location

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