Provider Demographics
NPI:1851315535
Name:BRIDGEWAY INC
Entity Type:Organization
Organization Name:BRIDGEWAY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC LPHA
Authorized Official - Phone:309-344-4200
Mailing Address - Street 1:2323 WINDISH DR
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-9780
Mailing Address - Country:US
Mailing Address - Phone:309-344-4200
Mailing Address - Fax:309-344-2200
Practice Address - Street 1:2323 WINDISH DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-9780
Practice Address - Country:US
Practice Address - Phone:309-344-4200
Practice Address - Fax:309-344-4281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X, 207Q00000X, 2084P0800X, 2084P0804X, 251S00000X, 261QM0801X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001180005OtherCERTIFIC/LICENSE
IL001180005OtherCERTIFIC/LICENSE
IL=========002Medicaid
IL001180005OtherCERTIFIC/LICENSE
IL655362Medicare ID - Type UnspecifiedLCSW