MEDICARE: BRIDGEWELL RESIDENTIAL SERVICES, LLC

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	320800000X	Mental Illness Community Based Residential Treatment Facility
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1396692448
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWELL RESIDENTIAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	112 TIBURON CT
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-7085
Country	:	US
Telephone Number	:	919-394-6718
Fax Number	:	919-288-1276

Provider Business Practice Location Address
First Line	:	2801 MCLAIN ST.
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534
Country	:	US
Telephone Number	:	919-394-6718
Fax Number	:	919-288-1276

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

Provider Enumeration Date	:	03/16/2026
Last Update Date	:	03/16/2026

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