Healthcare Provider Details

I. General information

NPI: 1508659459
Provider Name (Legal Business Name): BRIGHTBRIDGE ABA NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2025
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N MAIN ST STE 2434
WINSTON SALEM NC
27101-3885
US

IV. Provider business mailing address

743 CENTRAL AVE
WOODMERE NY
11598-2614
US

V. Phone/Fax

Practice location:
  • Phone: 336-510-7910
  • Fax:
Mailing address:
  • Phone: 347-268-4827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LEONARD JEGER
Title or Position: CEO
Credential:
Phone: 336-245-9155