Provider Demographics
NPI:1033888375
Name:BRIDGE TO RESTORATION THERAPY SERVICES
Entity Type:Organization
Organization Name:BRIDGE TO RESTORATION THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HASINA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-885-2476
Mailing Address - Street 1:3373 SANDYHOOK CT SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-5281
Mailing Address - Country:US
Mailing Address - Phone:616-885-2476
Mailing Address - Fax:
Practice Address - Street 1:2920 FULLER AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3458
Practice Address - Country:US
Practice Address - Phone:616-885-2476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty