=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881102713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHTSON MENTAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2018
-----------------------------------------------------
Last Update Date | 01/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 68 WINDING HILL DR
-----------------------------------------------------
City | HACKETTSTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07840-5671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-580-8159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 68 WINDING HILL DR
-----------------------------------------------------
City | HACKETTSTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07840-5671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-580-8159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. PHILOMINA IGWECHI
-----------------------------------------------------
Credential | APN
-----------------------------------------------------
Telephone | 973-580-8159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 26NJ00508400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------