Healthcare Provider Details

I. General information

NPI: 1386510378
Provider Name (Legal Business Name): BRIGHTSTAR BEHAVIORAL HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5703 LACHMAN AVE NE
ALBERTVILLE MN
55301-3973
US

IV. Provider business mailing address

7722 MACKENZIE AVE NE
OTSEGO MN
55330-5031
US

V. Phone/Fax

Practice location:
  • Phone: 763-291-3169
  • Fax:
Mailing address:
  • Phone: 763-291-3169
  • Fax: 763-291-3169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. PIUS AWANDEM TANYIFOR
Title or Position: DIRECTOR
Credential: DNP, PMHNP-BC, APRN,
Phone: 763-291-3169