Healthcare Provider Details

I. General information

NPI: 1508194283
Provider Name (Legal Business Name): BRIDGE BACK TO LIFE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2857 W 8TH ST
BROOKLYN NY
11224-3604
US

IV. Provider business mailing address

2857 W 8TH ST
BROOKLYN NY
11224-3604
US

V. Phone/Fax

Practice location:
  • Phone: 718-265-4200
  • Fax: 718-265-8536
Mailing address:
  • Phone: 718-265-4200
  • Fax: 718-265-8536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number080296
License Number StateNY

VIII. Authorized Official

Name: ASHLEY ANDERSON
Title or Position: SOCIAL WORKER
Credential: LMSW
Phone: 718-265-4200