Provider Demographics
NPI:1790425924
Name:BRIDGE THERAPY
Entity Type:Organization
Organization Name:BRIDGE THERAPY
Other - Org Name:THE BRIDGE THERAPY LCSW, PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:607-245-6259
Mailing Address - Street 1:9 KATTELVILLE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-5821
Mailing Address - Country:US
Mailing Address - Phone:607-245-6259
Mailing Address - Fax:607-304-5373
Practice Address - Street 1:9 KATTELVILLE RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-5859
Practice Address - Country:US
Practice Address - Phone:607-245-6259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-29
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2727902Medicaid