Healthcare Provider Details

I. General information

NPI: 1073251377
Provider Name (Legal Business Name): BRIDGE TO BALANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 E BASELINE RD STE 103
TEMPE AZ
85283-1433
US

IV. Provider business mailing address

1222 E BASELINE RD STE 103
TEMPE AZ
85283-1433
US

V. Phone/Fax

Practice location:
  • Phone: 602-705-1011
  • Fax:
Mailing address:
  • Phone: 602-804-1182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MYRIO DAVIS
Title or Position: OWNER
Credential:
Phone: 602-804-1182