MEDICARE: BRIGHTBRIDGE ABA 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

General Provider Information

NPI Number	:	1376377606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHTBRIDGE ABA LLC

Provider Business Mailing Address
First Line	:	743 CENTRAL AVE
Second Line	:
City	:	WOODMERE
State	:	NY
Zip	:	11598-2614
Country	:	US
Telephone Number	:	516-510-9869
Fax Number	:

Provider Business Practice Location Address
First Line	:	743 CENTRAL AVE
Second Line	:
City	:	WOODMERE
State	:	NY
Zip	:	11598-2614
Country	:	US
Telephone Number	:	347-268-4827
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. LEONARD JEGER
Credential	:
Telephone Number	:	347-268-4827

Provider Enumeration Date	:	08/29/2024
Last Update Date	:	08/29/2024

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