Provider Demographics
NPI:1326661836
Name:BRIDGE CLINICS BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:BRIDGE CLINICS BEHAVIORAL HEALTH LLC
Other - Org Name:BRIDGE CLINICS BEHAVIORAL HEALTH LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATIFAT
Authorized Official - Middle Name:A
Authorized Official - Last Name:OYEKOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-495-5173
Mailing Address - Street 1:6357 ROCKVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-3920
Mailing Address - Country:US
Mailing Address - Phone:317-757-2563
Mailing Address - Fax:317-405-9970
Practice Address - Street 1:3702 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-2554
Practice Address - Country:US
Practice Address - Phone:317-757-2563
Practice Address - Fax:317-405-9970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-19
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty