Provider Demographics
NPI:1073990420
Name:BRIDGE THE GAP, INC
Entity Type:Organization
Organization Name:BRIDGE THE GAP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:LINN
Authorized Official - Last Name:LALUZERNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-526-3791
Mailing Address - Street 1:1415 E GREEN BAY ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3879
Mailing Address - Country:US
Mailing Address - Phone:715-526-3791
Mailing Address - Fax:715-526-5537
Practice Address - Street 1:1415 E GREEN BAY ST
Practice Address - Street 2:SUITE 111
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3879
Practice Address - Country:US
Practice Address - Phone:715-526-3791
Practice Address - Fax:715-526-5537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health