=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124523956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGES 4 INDEPENDENCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2018
-----------------------------------------------------
Last Update Date | 03/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 PHYLLIS CT
-----------------------------------------------------
City | YORKTOWN HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10598-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-269-2679
-----------------------------------------------------
Fax | 914-425-8725
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 KILIAN DR
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06811-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-392-0057
-----------------------------------------------------
Fax | 914-425-8725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MANAGING MEMBER
-----------------------------------------------------
Name | MR. MICHAEL D FERNANDES
-----------------------------------------------------
Credential | CRPA-RECOVERY COACH
-----------------------------------------------------
Telephone | 914-269-2679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------