# BRIDGE RESIDENTIAL HOME LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114781945
- **Authorized official:** WILDINE BURGESS (EXEC ADMIN)
- **Authorized official phone:** (602) 354-9252

## Contact information

- **Practice address:** 7343 W MALDONADO RD, LAVEEN, AZ 85339-7001
- **Practice address phone:** (602) 354-9252
- **Mailing address:** PO BOX 51382, PHOENIX, AZ 85076-1382

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 103TB0200X | Cognitive & Behavioral Psychologist | — | NULL | — |
| 103TB0200X | Cognitive & Behavioral Psychologist | — | — | — |
| 2084A0401X | Addiction Medicine (Psychiatry & Neurology) Physician | — | NULL | — |
| 2084A0401X | Addiction Medicine (Psychiatry & Neurology) Physician | — | — | — |
| 323P00000X | Psychiatric Residential Treatment Facility | — | NULL | Yes |
| 324500000X | Substance Abuse Rehabilitation Facility | — | NULL | — |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | — |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 02/12/2024
- **Last updated:** 02/12/2024