MEDICARE: BRIDGE TO AFFECTIVE WELLNES, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	2084P0802X	Addiction Psychiatry Physician
2	2084P0804X	Child & Adolescent Psychiatry Physician
3	2084P0805X	Geriatric Psychiatry Physician
4	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1366167256
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGE TO AFFECTIVE WELLNES, PLLC

Provider Business Mailing Address
First Line	:	1028 LEE-ANN DR. NE
Second Line	:	SUITE 60
City	:	CONCORD
State	:	NC
Zip	:	28025-2903
Country	:	US
Telephone Number	:	980-272-1908
Fax Number	:	704-787-9920

Provider Business Practice Location Address
First Line	:	1028 LEE-ANN DR. NE
Second Line	:	SUITE 60
City	:	CONCORD
State	:	NC
Zip	:	28025-2903
Country	:	US
Telephone Number	:	980-272-1908
Fax Number	:	704-787-9920

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ALISHA MASSEY PRYOR
Credential	:
Telephone Number	:	980-272-1908

Provider Enumeration Date	:	10/04/2022
Last Update Date	:	10/04/2022

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Directions to “BRIDGE TO AFFECTIVE WELLNES, PLLC ” Practice Location

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