MEDICARE: BRIDGEWAY COUNSELING 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	103TC1900X	Counseling Psychologist
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1902493851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWAY COUNSELING LLC

Provider Business Mailing Address
First Line	:	4204 16TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3312
Country	:	US
Telephone Number	:	612-242-0673
Fax Number	:

Provider Business Practice Location Address
First Line	:	4204 16TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3312
Country	:	US
Telephone Number	:	612-242-0673
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	ABDIFATAH ISSE NUUH
Credential	:	MAHHSA/ALD
Telephone Number	:	612-242-0673

Provider Enumeration Date	:	12/27/2020
Last Update Date	:	06/12/2023

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Directions to “BRIDGEWAY COUNSELING LLC ” Practice Location

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