Healthcare Provider Details

I. General information

NPI: 1518475383
Provider Name (Legal Business Name): BRIDGE PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 MAIN ST
OLD MYSTIC CT
06372-7700
US

IV. Provider business mailing address

PO BOX 0562 BRIDGE PSYCHOTHERAPY
OLD MYSTIC CT
06372
US

V. Phone/Fax

Practice location:
  • Phone: 860-214-7439
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006035
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier006035
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerLCSW- LICENSE
# 2
Identifier1306088984
Identifier TypeOTHER
Identifier State
Identifier IssuerINDIVIDUAL NPI

VIII. Authorized Official

Name: BRIDGET DOYLE- KUSY
Title or Position: OWNER/SOLE PROPRIETOR
Credential: LCSW
Phone: 860-214-7439