Provider Demographics
NPI:1578387544
Name:A BRIDGE BACK, INC.
Entity type:Organization
Organization Name:A BRIDGE BACK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIKTEREV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-414-3517
Mailing Address - Street 1:1655 N ARLINGTON HEIGHTS RD # 305
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-3982
Mailing Address - Country:US
Mailing Address - Phone:844-427-6739
Mailing Address - Fax:
Practice Address - Street 1:1655 N ARLINGTON HEIGHTS RD # 305
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3982
Practice Address - Country:US
Practice Address - Phone:844-427-6739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health