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General NPI Number Information
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NPI Number | 1528822350
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Entity Type | Organization
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Legal Business Name | BRIDGE RESIDENTIAL LLC
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Dates
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Enumeration Date | 02/12/2024
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 7011 S 30TH LN
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City | PHOENIX
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State | AZ
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Zip | 85041-9313
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Country | US
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Telephone | 602-354-9252
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 51382
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City | PHOENIX
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State | AZ
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Zip | 85076-1382
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXEC ADMIN
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Name | WILDINE BURGESS
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Credential |
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Telephone | 602-354-9252
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 163WA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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