Provider Demographics
NPI:1194132175
Name:BRIDGE BACK TO LIFE INC
Entity type:Organization
Organization Name:BRIDGE BACK TO LIFE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIREC TOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:CASACLCSWR
Authorized Official - Phone:212-679-4960
Mailing Address - Street 1:4271 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5708
Mailing Address - Country:US
Mailing Address - Phone:516-520-6600
Mailing Address - Fax:
Practice Address - Street 1:4271 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5708
Practice Address - Country:US
Practice Address - Phone:516-520-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003103101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty