Organization
ILLINOIS MEDICAID-SUBSTANCE ABUSE MACOMB
Active
Organization
ILLINOIS MEDICAID-SUBSTANCE ABUSE MACOMB
Active
Parent organization
BRIDGEWAY INC
Organization subpart
Yes
Provider details
NPI number
Legal business name
BRIDGEWAY INC
Authorized official
MR. BILL A NELSON LCPC (CEO)
(309) 344-4200
Entity
Organization
Contact information
Practice address
900 S DEER RD, MACOMB, IL 61455-2639
(309) 837-4876
Mailing address
900 S DEER RD, MACOMB, IL 61455-2639
(309) 837-4876
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
A-0118-0010-A
IL
2084P0800X
Psychiatry Physician
—
IL
2084P0804X
Child & Adolescent Psychiatry Physician
—
IL
261QM2800X
Methadone Clinic
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
—
IL
Other
Enumeration date
09/09/2015
Last updated
08/19/2019
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