Provider Demographics
NPI:1508194283
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:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:718-265-4200
Mailing Address - Street 1:2857 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-3604
Mailing Address - Country:US
Mailing Address - Phone:718-265-4200
Mailing Address - Fax:718-265-8536
Practice Address - Street 1:2857 W 8TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-3604
Practice Address - Country:US
Practice Address - Phone:718-265-4200
Practice Address - Fax:718-265-8536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080296261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080296OtherLMSW