Provider Demographics
NPI:1659039857
Name:BRIDGEWAY BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:BRIDGEWAY BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:IRMA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-749-1104
Mailing Address - Street 1:5341 CAROL ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2002
Mailing Address - Country:US
Mailing Address - Phone:847-722-4901
Mailing Address - Fax:
Practice Address - Street 1:1440 RENAISSANCE DR STE 125
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1414
Practice Address - Country:US
Practice Address - Phone:847-722-4901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-04
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1578817003Medicaid