=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881922508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGE BACK TO LIFE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2009
-----------------------------------------------------
Last Update Date | 11/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 REMSEN ST 10TH FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11201-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-852-5552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 REMSEN ST 10TH FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11201-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-852-5552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | BETSY J HAMILTON
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 718-852-5552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 079825-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------