Healthcare Provider Details

I. General information

NPI: 1518883388
Provider Name (Legal Business Name): BRIDGE TO HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20282 CHANTICLEER DR
OREGON CITY OR
97045-9826
US

IV. Provider business mailing address

20282 CHANTICLEER DR
OREGON CITY OR
97045-9826
US

V. Phone/Fax

Practice location:
  • Phone: 240-355-1325
  • Fax:
Mailing address:
  • Phone: 240-355-1325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: WONDAYE TAMENE DERESSA
Title or Position: EXECUTIVE DIRECTOR
Credential: APRN
Phone: 240-355-1325