Provider Demographics
NPI:1487058517
Name:BRIDGING THE GAP SERIVICES LLC
Entity type:Organization
Organization Name:BRIDGING THE GAP SERIVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCREARY
Authorized Official - Suffix:
Authorized Official - Credentials:MHS CSC-AD
Authorized Official - Phone:240-550-2514
Mailing Address - Street 1:7902 OLD BRANCH AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-1627
Mailing Address - Country:US
Mailing Address - Phone:240-318-5790
Mailing Address - Fax:240-318-3551
Practice Address - Street 1:2511 EUTAW PL STE 204
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-5202
Practice Address - Country:US
Practice Address - Phone:410-528-8692
Practice Address - Fax:410-528-8675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC1761251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD842250Medicaid