Basic Information
| Provider Information | |||||||||
| NPI: | 1003353244 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY BRIDGES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WOMEN'S TRANSITION PROJECT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W BASELINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852029098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808317566 | ||||||||
| FaxNumber: | 4808317576 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 O'HARA AVENUE | ||||||||
| Address2: | |||||||||
| City: | BISBEE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204328068 | ||||||||
| FaxNumber: | 5204326962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2017 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4808317566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY BRIDGES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | LISAC | ||||||||
| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 343900000X | BH5106 | AZ | N | Transportation Services | Non-emergency Medical Transport (VAN) | 324500000X | BH5106 | AZ | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 237236 | 01 | AZ | AHCCCS | OTHER | BH5106 | 01 | AZ | ADHS | OTHER |