Provider Demographics
NPI:1881922508
Name:BRIDGE BACK TO LIFE CENTER
Entity type:Organization
Organization Name:BRIDGE BACK TO LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:718-852-5552
Mailing Address - Street 1:175 REMSEN ST
Mailing Address - Street 2:10TH FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-4300
Mailing Address - Country:US
Mailing Address - Phone:718-852-5552
Mailing Address - Fax:
Practice Address - Street 1:175 REMSEN ST
Practice Address - Street 2:10TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4300
Practice Address - Country:US
Practice Address - Phone:718-852-5552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079825-1261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY079825-1OtherLMSW