Provider Demographics
NPI:1235992322
Name:BRIDGESTONE MENTAL WELLNESS & THERAPY
Entity Type:Organization
Organization Name:BRIDGESTONE MENTAL WELLNESS & THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:FAMOGUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-441-1888
Mailing Address - Street 1:43736 TOLAMAC DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4761
Mailing Address - Country:US
Mailing Address - Phone:240-441-1888
Mailing Address - Fax:
Practice Address - Street 1:43736 TOLAMAC DR
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4761
Practice Address - Country:US
Practice Address - Phone:240-441-1888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)