MEDICARE: BRIGHTSIDE PSYCHOLOGY & INTERNAL MEDICINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH10506	FL
2	174400000X	Specialist	ME110882	FL
3	103TC1900X	Counseling Psychologist	PY8298	FL
4	103TC0700X	Clinical Psychologist	PY7723	FL
5	103TC0700X	Clinical Psychologist	PY7638	FL

General Provider Information

NPI Number	:	1376846584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHTSIDE PSYCHOLOGY & INTERNAL MEDICINE LLC

Provider Business Mailing Address
First Line	:	1277 N SEMORAN BLVD
Second Line	:	SUITE 107
City	:	ORLANDO
State	:	FL
Zip	:	32807-3569
Country	:	US
Telephone Number	:	407-601-7748
Fax Number	:	407-601-7749

Provider Business Practice Location Address
First Line	:	1277 N SEMORAN BLVD
Second Line	:	SUITE 107
City	:	ORLANDO
State	:	FL
Zip	:	32807-3569
Country	:	US
Telephone Number	:	407-601-7748
Fax Number	:	407-601-7749

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KAMIR MARRERO
Credential	:	PSYD
Telephone Number	:	407-601-7748

Provider Enumeration Date	:	12/09/2010
Last Update Date	:	02/03/2012

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