=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174197073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHTSIDE THERAPY, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2021
-----------------------------------------------------
Last Update Date | 12/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7512 CYPRESS GARDENS BLVD
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33884-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-337-6243
-----------------------------------------------------
Fax | 352-717-6829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7512 CYPRESS GARDENS BLVD
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33884-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 352-717-6829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | ISABELLA MARTINEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-337-6243
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------