Provider Demographics
NPI:1437375888
Name:BRIDGES EMOTIONAL WELLNESS CLINIC, INC
Entity Type:Organization
Organization Name:BRIDGES EMOTIONAL WELLNESS CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:CECILIA
Authorized Official - Last Name:OSTERHOLT-POLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-969-6600
Mailing Address - Street 1:4235 FLAGSTAFF COVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4418
Mailing Address - Country:US
Mailing Address - Phone:260-969-6600
Mailing Address - Fax:260-969-6601
Practice Address - Street 1:4235 FLAGSTAFF COVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4418
Practice Address - Country:US
Practice Address - Phone:260-969-6600
Practice Address - Fax:260-969-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200373680Medicaid
IN200373680Medicaid
IN216230Medicare PIN