Healthcare Provider Details

I. General information

NPI: 1710401708
Provider Name (Legal Business Name): COMMUNITY BRIDGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 E PIMA ST
PHOENIX AZ
85034
US

IV. Provider business mailing address

1855 W BASELINE RD STE 101
MESA AZ
85202-9098
US

V. Phone/Fax

Practice location:
  • Phone: 602-407-6280
  • Fax:
Mailing address:
  • Phone: 480-831-7566
  • Fax: 480-775-2457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberOTC7924
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberOTC7924
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberOTC7924
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberOTC7924
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberOTC7924
License Number StateAZ

VIII. Authorized Official

Name: JOHN HOGEBOOM
Title or Position: PRESIDENT/CEO
Credential:
Phone: 480-831-7566