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General NPI Number Information
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NPI Number | 1255050357
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Entity Type | Organization
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Legal Business Name | BRIGHTSIDE BEHAVIORAL CENTER INC
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Dates
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Enumeration Date | 08/23/2022
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Last Update Date | 10/12/2022
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Provider Practice Location Address
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Address Line | 1750 W BROADWAY ST STE 120
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City | OVIEDO
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State | FL
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Zip | 32765-9618
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Country | US
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Telephone | 786-715-3175
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Fax |
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Provider Business Mailing Address
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Address Line | 11037 SITING PL
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City | ORLANDO
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State | FL
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Zip | 32825-7227
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Country | US
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Telephone | 786-715-3175
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | ANNIET JORGE GOMEZ
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Credential |
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Telephone | 913-952-4162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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