MEDICARE: BRIGHT MIND THERAPY

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	106E00000X	Assistant Behavior Analyst
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1629759097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHT MIND THERAPY

Provider Business Mailing Address
First Line	:	26439 SIMS ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-4129
Country	:	US
Telephone Number	:	313-888-6188
Fax Number	:

Provider Business Practice Location Address
First Line	:	26439 SIMS ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-4129
Country	:	US
Telephone Number	:	313-888-6188
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HASSAN MAZLOUM
Credential	:
Telephone Number	:	313-888-6188

Provider Enumeration Date	:	07/28/2023
Last Update Date	:	08/03/2023

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Directions to “BRIGHT MIND THERAPY ” Practice Location

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