Provider Demographics
NPI:1790102051
Name:BRIDGE BACK TO LIFE CENTER, INC.
Entity Type:Organization
Organization Name:BRIDGE BACK TO LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R, SAP
Authorized Official - Phone:516-520-6600
Mailing Address - Street 1:4271 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5708
Mailing Address - Country:US
Mailing Address - Phone:516-520-6600
Mailing Address - Fax:516-520-6750
Practice Address - Street 1:1688 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3547
Practice Address - Country:US
Practice Address - Phone:718-447-5700
Practice Address - Fax:718-442-8945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1411106771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01439087Medicaid