Provider Demographics
NPI:1356839187
Name:BRIDGE TO ADULTHOOD, LLC
Entity Type:Organization
Organization Name:BRIDGE TO ADULTHOOD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:270-987-4456
Mailing Address - Street 1:5345 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ALLENSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42204-9024
Mailing Address - Country:US
Mailing Address - Phone:270-987-4456
Mailing Address - Fax:
Practice Address - Street 1:5345 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:ALLENSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42204-9024
Practice Address - Country:US
Practice Address - Phone:270-987-4456
Practice Address - Fax:888-270-7319
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:2025
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-26
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY2532421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100496400Medicaid