MEDICARE: BRIDGES ACADEMY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	10-7278	IL
2	251S00000X	Community/Behavioral Health Agency	10-7278	IL

General Provider Information

NPI Number	:	1083010342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGES ACADEMY, LLC

Provider Business Mailing Address
First Line	:	5911 N LEADER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5625
Country	:	US
Telephone Number	:	773-332-7382
Fax Number	:	773-305-0915

Provider Business Practice Location Address
First Line	:	5911 N LEADER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5625
Country	:	US
Telephone Number	:	773-332-7382
Fax Number	:	773-305-0915

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JAYME L CROOKS
Credential	:	MA, BCBA
Telephone Number	:	773-332-7382

Provider Enumeration Date	:	11/14/2014
Last Update Date	:	11/14/2014

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Directions to “BRIDGES ACADEMY, LLC ” Practice Location

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