MEDICARE: BRIDGESIDE COUNSELING SERVICES, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1285307348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGESIDE COUNSELING SERVICES, PLLC

Provider Business Mailing Address
First Line	:	3173 WRIGHTSVILLE AVE
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-4184
Country	:	US
Telephone Number	:	910-769-5353
Fax Number	:	910-660-0526

Provider Business Practice Location Address
First Line	:	3173 WRIGHTSVILLE AVE
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-4184
Country	:	US
Telephone Number	:	910-769-5353
Fax Number	:	910-660-0526

Authorized Official
Title or Position	:	OWNER
Name	:	PATRICIA DALE ESTADT
Credential	:	LCMHC
Telephone Number	:	931-769-5353

Provider Enumeration Date	:	07/26/2021
Last Update Date	:	07/26/2021

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