Healthcare Provider Details

I. General information

NPI: 1881922508
Provider Name (Legal Business Name): BRIDGE BACK TO LIFE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 REMSEN ST 10TH FLOOR
BROOKLYN NY
11201-4300
US

IV. Provider business mailing address

175 REMSEN ST 10TH FLOOR
BROOKLYN NY
11201-4300
US

V. Phone/Fax

Practice location:
  • Phone: 718-852-5552
  • Fax:
Mailing address:
  • Phone: 718-852-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number079825-1
License Number StateNY

VIII. Authorized Official

Name: BETSY J HAMILTON
Title or Position: SOCIAL WORKER
Credential: LMSW
Phone: 718-852-5552