Healthcare Provider Details

I. General information

NPI: 1619609823
Provider Name (Legal Business Name): BRIDGE TO WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/27/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 WILLIAM ST
NEW BEDFORD MA
02740-6052
US

IV. Provider business mailing address

235 CHAVENSON ST
FALL RIVER MA
02723-2701
US

V. Phone/Fax

Practice location:
  • Phone: 774-488-0049
  • Fax:
Mailing address:
  • Phone: 774-488-0049
  • 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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ALICIA DAVILA
Title or Position: CLINICAL SOCIAL WORKER
Credential: LICSW
Phone: 774-488-0049