Healthcare Provider Details

I. General information

NPI: 1437375888
Provider Name (Legal Business Name): BRIDGES EMOTIONAL WELLNESS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 FLAGSTAFF COVE
FORT WAYNE IN
46815-4418
US

IV. Provider business mailing address

4235 FLAGSTAFF COVE
FORT WAYNE IN
46815-4418
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-6600
  • Fax: 260-969-6601
Mailing address:
  • Phone: 260-969-6600
  • Fax: 260-969-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: AGNES CECILIA OSTERHOLT-POLSTON
Title or Position: PRESIDENT
Credential:
Phone: 260-969-6600