Provider Demographics
NPI:1770365413
Name:BRIDGES TO CHANGE
Entity type:Organization
Organization Name:BRIDGES TO CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEM ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:TRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:KILDOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-374-3730
Mailing Address - Street 1:PO BOX 16576
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7916 SE FOSTER RD STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4289
Practice Address - Country:US
Practice Address - Phone:503-465-2749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIDGES TO CHANGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty