Provider Demographics
NPI:1225427917
Name:BRIDGEWATER SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:BRIDGEWATER SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:BURKHARDT-SIDEBOTTOM
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:734-276-2765
Mailing Address - Street 1:8139 ERNST RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48158-9565
Mailing Address - Country:US
Mailing Address - Phone:734-276-2765
Mailing Address - Fax:
Practice Address - Street 1:8139 ERNST RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48158-9565
Practice Address - Country:US
Practice Address - Phone:734-276-2765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-18
Last Update Date:2015-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801087977261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health