Provider Demographics
NPI:1417195785
Name:THE BRIDGE AT BROOKSTOWN
Entity Type:Organization
Organization Name:THE BRIDGE AT BROOKSTOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-725-8646
Mailing Address - Street 1:235 S CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5230
Mailing Address - Country:US
Mailing Address - Phone:336-725-8646
Mailing Address - Fax:336-725-8654
Practice Address - Street 1:235 S CHERRY ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5230
Practice Address - Country:US
Practice Address - Phone:336-725-8646
Practice Address - Fax:336-725-8654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL034236101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty