MEDICARE: BRIDGEWAY PSYCHIATRIC CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	61404	OTHER	LA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1366433278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWAY PSYCHIATRIC CENTER, INC.

Provider Business Mailing Address
First Line	:	3451 5TH AVE
Second Line	:	SUITE A
City	:	LAKE CHARLES
State	:	LA
Zip	:	70607-2127
Country	:	US
Telephone Number	:	337-562-0211
Fax Number	:	337-562-0212

Provider Business Practice Location Address
First Line	:	3451 5TH AVE
Second Line	:	SUITE A
City	:	LAKE CHARLES
State	:	LA
Zip	:	70607-2127
Country	:	US
Telephone Number	:	337-562-0211
Fax Number	:	337-562-0212

Authorized Official
Title or Position	:	REGIONAL DIRECTOR
Name	:	ANNE DILL
Credential	:	R.N.
Telephone Number	:	337-785-8003

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	04/30/2010

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