MEDICARE: BRIDGEWAY THERAPEUTIC SERVICES INC

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1659098903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWAY THERAPEUTIC SERVICES INC

Provider Business Mailing Address
First Line	:	1200 2ND AVE S FL LL
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2513
Country	:	US
Telephone Number	:	612-323-9492
Fax Number	:	612-314-8958

Provider Business Practice Location Address
First Line	:	1200 2ND AVE S FL LL
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2513
Country	:	US
Telephone Number	:	612-323-9492
Fax Number	:	612-314-8958

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ADNA MUSTAFA ABUKAR
Credential	:
Telephone Number	:	612-323-9492

Provider Enumeration Date	:	10/26/2022
Last Update Date	:	10/26/2022

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