=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467344093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLAN BRIDGE WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2025
-----------------------------------------------------
Last Update Date | 08/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 MONTICELLO AVE STE 1867
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23510-2571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-346-2110
-----------------------------------------------------
Fax | 757-687-9927
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 MONTICELLO AVE STE 1867
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23510-2571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-346-2110
-----------------------------------------------------
Fax | 757-687-9927
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANGER
-----------------------------------------------------
Name | GABADIAH MCCLAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-820-9900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------