Healthcare Provider Details

I. General information

NPI: 1306214960
Provider Name (Legal Business Name): BAINBRIDGE HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PASSAIC ST
HACKENSACK NJ
07601-3525
US

IV. Provider business mailing address

200 PASSAIC ST
HACKENSACK NJ
07601-3525
US

V. Phone/Fax

Practice location:
  • Phone: 551-800-7101
  • Fax:
Mailing address:
  • Phone: 551-800-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number37PC00526200
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. MARA OLIVA
Title or Position: DIRECTOR
Credential: MA, LPC, LMHC
Phone: 201-919-6184