Provider Demographics
NPI:1558050054
Name:BRIGHT WATERS PSYCHIATRY AND WELLNESS LLC
Entity Type:Organization
Organization Name:BRIGHT WATERS PSYCHIATRY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:443-248-0457
Mailing Address - Street 1:516 N CHARLES ST STE 305
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5051
Mailing Address - Country:US
Mailing Address - Phone:410-431-1656
Mailing Address - Fax:410-701-3921
Practice Address - Street 1:516 N CHARLES ST STE 305
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5051
Practice Address - Country:US
Practice Address - Phone:410-431-1656
Practice Address - Fax:410-701-3921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-02
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty