Provider Demographics
NPI:1144847880
Name:BRIDGEWATER COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:BRIDGEWATER COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-520-3339
Mailing Address - Street 1:10551 VONDER HAAR LN
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-4316
Mailing Address - Country:US
Mailing Address - Phone:618-520-3339
Mailing Address - Fax:
Practice Address - Street 1:10551 VONDER HAAR LN
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-4316
Practice Address - Country:US
Practice Address - Phone:618-520-3339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487841714OtherNPI
MO2012036897OtherPROFESSIONAL CLINICAL SOCIAL WORK LICENSE
IL149015007OtherPROFESSIONAL LICENSE