Healthcare Provider Details

I. General information

NPI: 1578788188
Provider Name (Legal Business Name): BRIDGEWAY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 W DIVISION ST
KEWANEE IL
61443-3390
US

IV. Provider business mailing address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

V. Phone/Fax

Practice location:
  • Phone: 309-853-4325
  • Fax: 309-853-4385
Mailing address:
  • Phone: 309-344-4200
  • Fax: 309-344-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM NELSON
Title or Position: CEO
Credential:
Phone: 309-344-2323