Healthcare Provider Details

I. General information

NPI: 1861776213
Provider Name (Legal Business Name): BRIDGEWAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S DEER RD
MACOMB IL
61455-2604
US

IV. Provider business mailing address

590 S DEER RD
MACOMB IL
61455-2639
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-4876
  • Fax: 309-833-1531
Mailing address:
  • Phone: 309-836-9910
  • Fax: 309-836-3422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number04016
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number04016
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number04016
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number04016
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number04016
License Number StateIL

VIII. Authorized Official

Name: STACI DANNER
Title or Position: BILLING MANAGER
Credential:
Phone: 309-344-2323