Provider Demographics
NPI:1962793539
Name:BRIDGEWAY RECOVERY SERVICES
Entity type:Organization
Organization Name:BRIDGEWAY RECOVERY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COD COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:951-235-4115
Mailing Address - Street 1:3325 HAROLD DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1339
Mailing Address - Country:US
Mailing Address - Phone:503-363-4820
Mailing Address - Fax:503-363-4820
Practice Address - Street 1:3325 HAROLD DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1339
Practice Address - Country:US
Practice Address - Phone:503-363-4820
Practice Address - Fax:503-363-4820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health