Provider Demographics
NPI:1518475383
Name:BRIDGE PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:BRIDGE PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:DOYLE- KUSY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-214-7439
Mailing Address - Street 1:PO BOX 0562
Mailing Address - Street 2:BRIDGE PSYCHOTHERAPY
Mailing Address - City:OLD MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06372-7700
Practice Address - Country:US
Practice Address - Phone:860-214-7439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0060351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT006035OtherLCSW- LICENSE
1306088984OtherINDIVIDUAL NPI