Healthcare Provider Details

I. General information

NPI: 1659098903
Provider Name (Legal Business Name): BRIDGEWAY THERAPEUTIC SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 2ND AVE S FL LL
MINNEAPOLIS MN
55403-2513
US

IV. Provider business mailing address

1200 2ND AVE S FL LL
MINNEAPOLIS MN
55403-2513
US

V. Phone/Fax

Practice location:
  • Phone: 612-323-9492
  • Fax: 612-314-8958
Mailing address:
  • Phone: 612-323-9492
  • Fax: 612-314-8958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ADNA MUSTAFA ABUKAR
Title or Position: PRESIDENT
Credential:
Phone: 612-323-9492