Provider Demographics
NPI:1356969505
Name:BRIDGEWAY WELLNESS CENTER LLC
Entity type:Organization
Organization Name:BRIDGEWAY WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LATANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:617-905-8183
Mailing Address - Street 1:350 LINCOLN ST STE 2400
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-1579
Mailing Address - Country:US
Mailing Address - Phone:617-446-3705
Mailing Address - Fax:
Practice Address - Street 1:350 LINCOLN ST STE 2400
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-1579
Practice Address - Country:US
Practice Address - Phone:617-446-3705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-13
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty