Healthcare Provider Details

I. General information

NPI: 1518918101
Provider Name (Legal Business Name): BRIDGE BACK TO LIFE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 STEWART AVE STE 101
BETHPAGE NY
11714-3637
US

IV. Provider business mailing address

1065 STEWART AVE STE 101
BETHPAGE NY
11714-3637
US

V. Phone/Fax

Practice location:
  • Phone: 516-520-6600
  • Fax: 516-520-6750
Mailing address:
  • Phone: 516-520-6600
  • Fax: 516-520-6750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH CARUCCI ROSSI
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 516-520-6600