Healthcare Provider Details

I. General information

NPI: 1457289019
Provider Name (Legal Business Name): BRIDGEWELL ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1999 PARKER CT
STONE MOUNTAIN GA
30087-3651
US

IV. Provider business mailing address

936 LOST CREEK CIR
STONE MOUNTAIN GA
30088-2119
US

V. Phone/Fax

Practice location:
  • Phone: 678-599-2798
  • Fax:
Mailing address:
  • Phone: 678-599-2798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: LATONYA DONALD
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 678-599-2798