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General NPI Number Information
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NPI Number | 1609812130
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Entity Type | Organization
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Legal Business Name | BRIDGE COUNSELING CENTER INC
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Dates
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Enumeration Date | 06/22/2006
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Last Update Date | 07/20/2021
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Provider Practice Location Address
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Address Line | 269 E MAIN ST SUITE F2
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City | SMITHTOWN
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State | NY
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Zip | 11787-2832
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Country | US
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Telephone | 631-360-6695
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 286
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City | SMITHTOWN
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State | NY
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Zip | 11787-0286
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Country | US
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Telephone | 631-360-6695
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Fax |
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Authorized Official
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Title or Position | PRESIDENT , DIRECTOR
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Name | MS. LISA F RAIA
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Credential | LCSW-R
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Telephone | 631-360-6695
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 075024-1
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License Number State | NY
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