1639560915 NPI number — BRIDGE THE GAP ADDICTION AND MENTAL HEALTH SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639560915 NPI number — BRIDGE THE GAP ADDICTION AND MENTAL HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGE THE GAP ADDICTION AND MENTAL HEALTH SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BRIDGE THE GAP ADDICTION AND MENTAL HEALTH SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639560915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
835 S 7TH STREET
Provider Second Line Business Mailing Address:
3452
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-174-2566
Provider Business Mailing Address Fax Number:
502-305-6578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 W BROADWAY, SUITE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-417-2566
Provider Business Practice Location Address Fax Number:
502-305-6578
Provider Enumeration Date:
02/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PARRISH
Authorized Official First Name:
HAZEL
Authorized Official Middle Name:
DELL
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
502-417-2566

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1078 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3245S0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 71004478660 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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