Provider Demographics
NPI:1003205261
Name:BRIDGE TO INDEPENDENT LIVING, LLC.
Entity type:Organization
Organization Name:BRIDGE TO INDEPENDENT LIVING, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANTOINETTE
Authorized Official - Last Name:CAVINESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-882-6444
Mailing Address - Street 1:5000 2ND ST NW APT 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-4171
Mailing Address - Country:US
Mailing Address - Phone:202-882-6444
Mailing Address - Fax:
Practice Address - Street 1:5004 2ND ST NW APT 1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-4170
Practice Address - Country:US
Practice Address - Phone:231-740-4625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities