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General NPI Number Information
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NPI Number | 1508194283
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Entity Type | Organization
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Legal Business Name | BRIDGE BACK TO LIFE, INC
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Dates
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Enumeration Date | 11/18/2009
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Last Update Date | 11/18/2009
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Provider Practice Location Address
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Address Line | 2857 W 8TH ST
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City | BROOKLYN
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State | NY
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Zip | 11224-3604
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Country | US
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Telephone | 718-265-4200
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Fax | 718-265-8536
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Provider Business Mailing Address
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Address Line | 2857 W 8TH ST
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City | BROOKLYN
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State | NY
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Zip | 11224-3604
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Country | US
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Telephone | 718-265-4200
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Fax | 718-265-8536
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | ASHLEY ANDERSON
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Credential | LMSW
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Telephone | 718-265-4200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 080296
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License Number State | NY
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