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General NPI Number Information
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NPI Number | 1568907616
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Entity Type | Organization
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Legal Business Name | BRIGHT STAR COMMUNITY OUTREACH
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Dates
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Enumeration Date | 12/28/2016
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Last Update Date | 12/28/2016
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Provider Practice Location Address
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Address Line | 4518 S COTTAGE GROVE AVE
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City | CHICAGO
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State | IL
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Zip | 60653-4395
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Country | US
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Telephone | 773-373-5220
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Fax | 312-982-2566
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Provider Business Mailing Address
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Address Line | 3473 S KING DR SUITE 334
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City | CHICAGO
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State | IL
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Zip | 60616-4108
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Country | US
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Telephone | 773-373-5220
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Fax | 312-982-2566
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Authorized Official
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Title or Position | CLINICAL SUPERVISOR
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Name | DR. CYNTHIA LANGLEY
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Credential | PSY.D.
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Telephone | 309-645-5445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071.008564
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License Number State | IL
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