Healthcare Provider Details

I. General information

NPI: 1336566694
Provider Name (Legal Business Name): BRIDGE BACK TO LIFE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 REMSEN ST SUITE 1010
BROOKLYN NY
11201-4333
US

IV. Provider business mailing address

4271 HEMPSTEAD TPKE
BETHPAGE NY
11714-5708
US

V. Phone/Fax

Practice location:
  • Phone: 718-852-5552
  • Fax: 718-852-5666
Mailing address:
  • Phone: 516-520-6600
  • Fax: 516-520-6750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number141211343
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number141211343
License Number StateNY

VIII. Authorized Official

Name: MR. GARY BUTCHEN
Title or Position: PRESIDENT
Credential: LCSW-R, SAP
Phone: 516-520-6600