Provider Demographics
NPI:1659412997
Name:BRIDGING THE GAP WITH LIFE SKILLS
Entity Type:Organization
Organization Name:BRIDGING THE GAP WITH LIFE SKILLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY SERVIES DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-833-2544
Mailing Address - Street 1:204 N PERSON ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1047
Mailing Address - Country:US
Mailing Address - Phone:919-833-2544
Mailing Address - Fax:919-833-0939
Practice Address - Street 1:2507 BLACKWOLF RUN LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-5425
Practice Address - Country:US
Practice Address - Phone:919-250-9546
Practice Address - Fax:919-250-7569
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE SKILLS COUNSELING, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-09
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL092571322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604129Medicaid