=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386510378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHTSTAR BEHAVIORAL HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2025
-----------------------------------------------------
Last Update Date | 10/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7420 UNITY AVE N STE 305
-----------------------------------------------------
City | BROOKLYN PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55443-3136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-291-3169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7722 MACKENZIE AVE NE
-----------------------------------------------------
City | OTSEGO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55330-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-291-3169
-----------------------------------------------------
Fax | 763-291-3169
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. PIUS AWANDEM TANYIFOR
-----------------------------------------------------
Credential | DNP, PMHNP-BC, APRN,
-----------------------------------------------------
Telephone | 763-291-3169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------