Healthcare Provider Details

I. General information

NPI: 1114140621
Provider Name (Legal Business Name): BRIDGEWAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 E COLLEGE ST
KEWANEE IL
61443-3703
US

IV. Provider business mailing address

137 E COLLEGE ST
KEWANEE IL
61443-3703
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-4331
  • Fax:
Mailing address:
  • Phone: 309-852-4331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3709841785020
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number020
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number020
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateIA
# 7
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateIL

VIII. Authorized Official

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