Healthcare Provider Details

I. General information

NPI: 1225427917
Provider Name (Legal Business Name): BRIDGEWATER SUPPORT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2015
Last Update Date: 01/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8139 ERNST RD
MANCHESTER MI
48158-9565
US

IV. Provider business mailing address

8139 ERNST RD
MANCHESTER MI
48158-9565
US

V. Phone/Fax

Practice location:
  • Phone: 734-276-2765
  • Fax:
Mailing address:
  • Phone: 734-276-2765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number6801087977
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6801087977
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6801087977
License Number StateMI

VIII. Authorized Official

Name: MRS. AMBER DAWN BURKHARDT-SIDEBOTTOM
Title or Position: CLINICAL SOCIAL WORKER
Credential: LMSW
Phone: 734-276-2765