Organization
BRIDGEWAY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STACI DANNER (BILLING MANAGER)
(309) 344-2323
Entity
Organization
Contact information
Practice address
590 S DEER RD, MACOMB, IL 61455-2604
(309) 837-4876
(309) 833-1531
Mailing address
590 S DEER RD, MACOMB, IL 61455-2639
(309) 836-9910
(309) 836-3422
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
04016
IL
101YM0800X
Mental Health Counselor
04016
IL
101YP2500X
Professional Counselor
04016
IL
104100000X
Social Worker
04016
IL
251S00000X
Community/Behavioral Health Agency
Primary
04016
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
04016
MENTAL HEALTH MEDICAID CERTIFICATE
IL
Enumeration date
10/04/2011
Last updated
11/30/2011
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