Healthcare Provider Details

I. General information

NPI: 1649192907
Provider Name (Legal Business Name): BRIDGEWAY PSYCHOLOGICAL AND COUNSELING SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 E CLARK ST STE 210
POCATELLO ID
83201-3357
US

IV. Provider business mailing address

1777 E CLARK ST STE 210
POCATELLO ID
83201-3357
US

V. Phone/Fax

Practice location:
  • Phone: 208-203-2088
  • Fax:
Mailing address:
  • Phone: 208-203-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW B OLSEN
Title or Position: OWNER
Credential: LCSW
Phone: 208-203-2088