Provider Demographics
NPI:1447965280
Name:BRIDGE ABA
Entity type:Organization
Organization Name:BRIDGE ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BCBA
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MS BCBA
Authorized Official - Phone:479-650-3802
Mailing Address - Street 1:6502 HILLTOP RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-7604
Mailing Address - Country:US
Mailing Address - Phone:479-650-3802
Mailing Address - Fax:
Practice Address - Street 1:900 ELLIS LOOP
Practice Address - Street 2:
Practice Address - City:POCOLA
Practice Address - State:OK
Practice Address - Zip Code:74902-2428
Practice Address - Country:US
Practice Address - Phone:479-650-3802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-17
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty