MEDICARE: BRIDGEWELL ALLIANCE, 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1457289019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWELL ALLIANCE, LLC

Provider Business Mailing Address
First Line	:	936 LOST CREEK CIR
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2119
Country	:	US
Telephone Number	:	678-599-2798
Fax Number	:

Provider Business Practice Location Address
First Line	:	1999 PARKER CT
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-3651
Country	:	US
Telephone Number	:	678-599-2798
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LATONYA DONALD
Credential	:	PH.D.
Telephone Number	:	678-599-2798

Provider Enumeration Date	:	05/12/2026
Last Update Date	:	05/12/2026

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