MEDICARE: BRIGHT SIDE OF THE MOON LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	1-11-9018

General Provider Information

NPI Number	:	1578911715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHT SIDE OF THE MOON LLC

Provider Business Mailing Address
First Line	:	3431 BRIDGE AVE
Second Line	:	UNIT 20
City	:	POINT PLEASANT BORO
State	:	NJ
Zip	:	08742-2745
Country	:	US
Telephone Number	:	732-644-3912
Fax Number	:

Provider Business Practice Location Address
First Line	:	3431 BRIDGE AVE
Second Line	:	UNIT 20
City	:	POINT PLEASANT BORO
State	:	NJ
Zip	:	08742-2745
Country	:	US
Telephone Number	:	732-644-3912
Fax Number	:

Authorized Official
Title or Position	:	OWNER/BCBA
Name	:	MS. NICOLE LEMPA
Credential	:	BCBA
Telephone Number	:	732-644-3912

Provider Enumeration Date	:	05/27/2016
Last Update Date	:	05/27/2016

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Directions to “BRIGHT SIDE OF THE MOON LLC ” Practice Location

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