Provider Demographics
NPI:1679961882
Name:YOUTH BRIDGE
Entity Type:Organization
Organization Name:YOUTH BRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MHPP
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-282-9492
Mailing Address - Street 1:250 E. CENTERTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72758
Mailing Address - Country:US
Mailing Address - Phone:479-795-1802
Mailing Address - Fax:
Practice Address - Street 1:250 E CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9240
Practice Address - Country:US
Practice Address - Phone:479-795-1802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management