Provider Demographics
NPI:1174914048
Name:BRIDGE TO SHORE RECOVERY, LLC
Entity type:Organization
Organization Name:BRIDGE TO SHORE RECOVERY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMISSIONS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:D
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-217-0480
Mailing Address - Street 1:3930 US 1 S
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7089
Mailing Address - Country:US
Mailing Address - Phone:904-540-4232
Mailing Address - Fax:
Practice Address - Street 1:3930 US 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7089
Practice Address - Country:US
Practice Address - Phone:904-540-4232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
323P00000X
FL5501324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME38055OtherMD
FLAPRN2520572OtherAPRN
FLSW16603OtherLCSW
FLMH17663OtherLMHC
FLMH16535OtherLMHC
FLSW18303OtherLCSW