=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023533940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT SIDE OF CHANGE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2017
-----------------------------------------------------
Last Update Date | 08/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 W CALLE TIERRA SANDIA
-----------------------------------------------------
City | SAHUARITA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85629-9034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-727-1661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4422 W CALLE JOCOBO
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85741-1830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-373-7111
-----------------------------------------------------
Fax | 520-328-8701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | NICOLE PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-441-4754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW16503
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------