=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508347162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT FUTURES WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2018
-----------------------------------------------------
Last Update Date | 10/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 422-426 HIGHLAND AVENUE
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-304-4961
-----------------------------------------------------
Fax | 203-306-2905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 104
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-0104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-304-4961
-----------------------------------------------------
Fax | 203-306-2905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | HEIDI B WILDSTEIN
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 203-304-4961
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 2442
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2080P0006X
-----------------------------------------------------
Taxonomy Name | Developmental - Behavioral Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------