Provider Demographics
NPI:1780974493
Name:THE BRIDGE FAMILY CENTER, INC
Entity type:Organization
Organization Name:THE BRIDGE FAMILY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERN
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VIRGIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-416-8455
Mailing Address - Street 1:1022 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1038 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2109
Practice Address - Country:US
Practice Address - Phone:860-313-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health