Basic Information
| Provider Information | |||||||||
| NPI: | 1326410986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDGES TO CHANGE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16576 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920576 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7916 SE FOSTER RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972064289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034652749 | ||||||||
| FaxNumber: | 5032082596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2015 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BESSETTE | ||||||||
| AuthorizedOfficialFirstName: | KATELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF TREATMENT SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5038587073 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA, LPC, CADCII | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 500703921 | 05 | OR | MEDICAID |