Healthcare Provider Details

I. General information

NPI: 1871425017
Provider Name (Legal Business Name): BRIDGE TO LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5035 S LINKS CIR
SUFFOLK VA
23435-2684
US

IV. Provider business mailing address

5035 S LINKS CIR
SUFFOLK VA
23435-2684
US

V. Phone/Fax

Practice location:
  • Phone: 757-516-3909
  • Fax:
Mailing address:
  • Phone: 757-516-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. CRYSTAL SMITH
Title or Position: DIRECTOR
Credential:
Phone: 757-516-3909