Provider Demographics
NPI:1235701046
Name:BRIDGE TO LIFE LLC
Entity Type:Organization
Organization Name:BRIDGE TO LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-419-4975
Mailing Address - Street 1:36 E 25TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5476
Mailing Address - Country:US
Mailing Address - Phone:410-419-4975
Mailing Address - Fax:
Practice Address - Street 1:36 E 25TH ST FL 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5476
Practice Address - Country:US
Practice Address - Phone:410-419-4975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-12
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility