Healthcare Provider Details

I. General information

NPI: 1396692448
Provider Name (Legal Business Name): BRIDGEWELL RESIDENTIAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 08/23/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MCLAIN ST.
GOLDSBORO NC
27534
US

IV. Provider business mailing address

112 TIBURON CT
GOLDSBORO NC
27534-7085
US

V. Phone/Fax

Practice location:
  • Phone: 919-394-6718
  • Fax: 919-288-1276
Mailing address:
  • Phone: 919-394-6718
  • Fax: 919-288-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. CANDRA NIKITA EDWARDS
Title or Position: OWNER, CLINICAL DIRECTOR
Credential: LCSW
Phone: 910-990-1190