Provider Demographics
NPI:1891959169
Name:BRIDGEWATER COUNSELING SERVICES PC
Entity Type:Organization
Organization Name:BRIDGEWATER COUNSELING SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:W
Authorized Official - Last Name:MANDEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:540-828-3663
Mailing Address - Street 1:108 WEST COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:VA
Mailing Address - Zip Code:22812-1124
Mailing Address - Country:US
Mailing Address - Phone:540-828-3663
Mailing Address - Fax:540-828-2322
Practice Address - Street 1:108 WEST COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:VA
Practice Address - Zip Code:22812-1124
Practice Address - Country:US
Practice Address - Phone:540-828-3663
Practice Address - Fax:540-828-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA08120003821041C0700X
VA09040029901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891959169Medicaid
VA219164OtherCOM-PSYCH
VA1891959169Medicaid
VA219164OtherCOM-PSYCH