Provider Demographics
NPI:1396279824
Name:THE BRIDGES WELLNESS GROUP, LLC.
Entity type:Organization
Organization Name:THE BRIDGES WELLNESS GROUP, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:NICKLESON
Authorized Official - Last Name:BATTLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCPC, LPC
Authorized Official - Phone:703-225-9118
Mailing Address - Street 1:7050 CHESAPEAKE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2345
Mailing Address - Country:US
Mailing Address - Phone:240-770-7204
Mailing Address - Fax:
Practice Address - Street 1:7050 CHESAPEAKE RD STE 104
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20784
Practice Address - Country:US
Practice Address - Phone:407-707-2042
Practice Address - Fax:866-473-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC024397355Medicaid
MD821004700Medicaid