Provider Demographics
NPI:1467780718
Name:BRIDGE BACK TO LIFE, INC.
Entity Type:Organization
Organization Name:BRIDGE BACK TO LIFE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LEIGH-ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BORRIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:718-447-5700
Mailing Address - Street 1:1688 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3533
Mailing Address - Country:US
Mailing Address - Phone:718-447-5700
Mailing Address - Fax:
Practice Address - Street 1:1688 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3533
Practice Address - Country:US
Practice Address - Phone:718-447-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080366261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080366OtherLEIGH ANN BORRIELLO, LMSW