=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689966558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGE HOUSE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2011
-----------------------------------------------------
Last Update Date | 05/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4150 EARHART BLVD
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70125-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-821-7122
-----------------------------------------------------
Fax | 504-827-8747
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4150 EARHART BLVD
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70125-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-821-7122
-----------------------------------------------------
Fax | 504-827-8747
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. ELSE DOROTHEA PEDERSEN-WASSON
-----------------------------------------------------
Credential | MBA, LAC
-----------------------------------------------------
Telephone | 504-821-7122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 057A
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 057B
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 057C
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------