Organization
BRIDGEWATER COUNSELING SERVICES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RENEE MARIE KELLER LCSW (PRINCIPAL)
(618) 520-3339
Entity
Organization
Contact information
Practice address
10551 VONDER HAAR LN, BREESE, IL 62230-4316
(618) 520-3339
Mailing address
10551 VONDER HAAR LN, BREESE, IL 62230-4316
(618) 520-3339
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1487841714
NPI
—
01
—
149015007
PROFESSIONAL LICENSE
IL
01
—
2012036897
PROFESSIONAL CLINICAL SOCIAL WORK LICENSE
MO
Enumeration date
06/29/2020
Last updated
06/05/2024
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