Healthcare Provider Details

I. General information

NPI: 1396279824
Provider Name (Legal Business Name): THE BRIDGES WELLNESS GROUP, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7050 CHESAPEAKE RD STE 104
HYATTSVILLE MD
20784
US

IV. Provider business mailing address

7050 CHESAPEAKE RD STE 104
HYATTSVILLE MD
20784-2345
US

V. Phone/Fax

Practice location:
  • Phone: 407-707-2042
  • Fax: 866-473-0669
Mailing address:
  • Phone: 240-770-7204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. MARVIN NICKLESON BATTLE JR.
Title or Position: CHIEF OPERATING OFFICER
Credential: LCPC, LPC
Phone: 703-225-9118