Healthcare Provider Details

I. General information

NPI: 1578677076
Provider Name (Legal Business Name): BRIDGEWAY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/13/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 HOSPITAL DRIVE
FORT WALTON BEACH FL
32548
US

IV. Provider business mailing address

137 HOSPITAL DR NE
FORT WALTON BEACH FL
32548-5063
US

V. Phone/Fax

Practice location:
  • Phone: 850-833-7512
  • Fax: 850-833-7434
Mailing address:
  • Phone: 850-833-7500
  • Fax: 850-833-7443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26039072238
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CLAYTON RANDALL MCALLISTER
Title or Position: CHIEF FINANCIAL OFFICER
Credential: MBA
Phone: 850-634-0050