=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245036094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGEWATER PSYCHIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2025
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1346 OLD BRIDGE RD STE 201
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-233-3693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7902 TYSONS ONE PL UNIT 2613
-----------------------------------------------------
City | TYSONS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22102-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-233-3693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. KRISTIN SMITH
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 804-234-3693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------