=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912319641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE BRIDGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2014
-----------------------------------------------------
Last Update Date | 05/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 89-31 161ST STREET
-----------------------------------------------------
City | QUEENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-557-1489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8931 161ST ST
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-6140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | PAULA SCOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-557-1489
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------