Healthcare Provider Details

I. General information

NPI: 1376846584
Provider Name (Legal Business Name): BRIGHTSIDE PSYCHOLOGY & INTERNAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 N SEMORAN BLVD SUITE 107
ORLANDO FL
32807-3569
US

IV. Provider business mailing address

1277 N SEMORAN BLVD SUITE 107
ORLANDO FL
32807-3569
US

V. Phone/Fax

Practice location:
  • Phone: 407-601-7748
  • Fax: 407-601-7749
Mailing address:
  • Phone: 407-601-7748
  • Fax: 407-601-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH10506
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME110882
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY8298
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7723
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7638
License Number StateFL

VIII. Authorized Official

Name: DR. KAMIR MARRERO
Title or Position: PRESIDENT
Credential: PSYD
Phone: 407-601-7748