Provider Demographics
NPI:1144420175
Name:HARBOR BRIDGE EMOTIONAL HEALTH, LLC
Entity Type:Organization
Organization Name:HARBOR BRIDGE EMOTIONAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:203-661-1054
Mailing Address - Street 1:406 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6215
Mailing Address - Country:US
Mailing Address - Phone:203-661-1054
Mailing Address - Fax:
Practice Address - Street 1:406 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6215
Practice Address - Country:US
Practice Address - Phone:203-661-1054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT02766103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty