Provider Demographics
NPI:1881968519
Name:ASSISI BRIDGE HOUSE INDEPENDENT LIVING PROGRAM
Entity type:Organization
Organization Name:ASSISI BRIDGE HOUSE INDEPENDENT LIVING PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DAMIEN
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, ACSW
Authorized Official - Phone:985-876-0490
Mailing Address - Street 1:1220 AYCOCK ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-6402
Mailing Address - Country:US
Mailing Address - Phone:985-876-0490
Mailing Address - Fax:985-876-7751
Practice Address - Street 1:700 LEVRON ST APT 12D
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-5574
Practice Address - Country:US
Practice Address - Phone:985-872-5529
Practice Address - Fax:985-857-8270
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC CHARITIES OF THE DIOCESE OF HOUMA-THIBODAUX
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2437324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility