Healthcare Provider Details

I. General information

NPI: 1356969505
Provider Name (Legal Business Name): BRIDGEWAY WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LINCOLN ST STE 2400
HINGHAM MA
02043-1579
US

IV. Provider business mailing address

350 LINCOLN ST STE 2400
HINGHAM MA
02043-1579
US

V. Phone/Fax

Practice location:
  • Phone: 617-446-3705
  • Fax:
Mailing address:
  • Phone: 617-446-3705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LATANYA DUNCAN
Title or Position: CO-OWNER/CLINICIAN
Credential: MA
Phone: 617-905-8183