Provider Demographics
| NPI: | 1528822350 |
|---|---|
| Name: | BRIDGE RESIDENTIAL LLC |
| Entity type: | Organization |
| Organization Name: | BRIDGE RESIDENTIAL LLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | EXEC ADMIN |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | WILDINE |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | BURGESS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 602-354-9252 |
| Mailing Address - Street 1: | PO BOX 51382 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | PHOENIX |
| Mailing Address - State: | AZ |
| Mailing Address - Zip Code: | 85076-1382 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 7011 S 30TH LN |
| Practice Address - Street 2: | |
| Practice Address - City: | PHOENIX |
| Practice Address - State: | AZ |
| Practice Address - Zip Code: | 85041-9313 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 602-354-9252 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2024-02-12 |
| Last Update Date: | 2024-02-12 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 323P00000X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
| No | 163WA0400X | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | ||
| No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) | ||
| No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
