=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235659780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT FUTURE COMMUNITY HEALTH CARE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2017
-----------------------------------------------------
Last Update Date | 03/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 S DUNDALK AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21222-4267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-912-4612
-----------------------------------------------------
Fax | 877-288-4626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 907 FOXWOOD LN
-----------------------------------------------------
City | ESSEX
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21221-5929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-413-8254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST/OWNER
-----------------------------------------------------
Name | EMMANUELLA OWOBU
-----------------------------------------------------
Credential | LCPC, CAC-AD
-----------------------------------------------------
Telephone | 443-912-4612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------