Provider Demographics
NPI:1093823817
Name:BRIDGEHAVEN, INC.
Entity Type:Organization
Organization Name:BRIDGEHAVEN, INC.
Other - Org Name:BRIDGEHAVEN MENTAL HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, CS
Authorized Official - Phone:502-585-9444
Mailing Address - Street 1:950 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2288
Mailing Address - Country:US
Mailing Address - Phone:502-585-9444
Mailing Address - Fax:502-585-9466
Practice Address - Street 1:950 S 1ST ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2288
Practice Address - Country:US
Practice Address - Phone:502-585-9444
Practice Address - Fax:502-585-9466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 251V00000X, 261QM0850X
KY800159251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100340960Medicaid
KY213150000OtherMAGELLAN
KY30606099Medicaid
KY318961OtherVALUE OPTIONS
KY7100340960Medicaid