MEDICARE: BRIGHTWAVE PSYCHIATRY PLLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1528993706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHTWAVE PSYCHIATRY PLLC

Provider Business Mailing Address
First Line	:	441 STUART LN
Second Line	:
City	:	FATE
State	:	TX
Zip	:	75189-4791
Country	:	US
Telephone Number	:	469-237-0381
Fax Number	:	972-692-5299

Provider Business Practice Location Address
First Line	:	441 STUART LN
Second Line	:
City	:	FATE
State	:	TX
Zip	:	75189-4791
Country	:	US
Telephone Number	:	469-237-0381
Fax Number	:	972-692-5299

Authorized Official
Title or Position	:	OWNER
Name	:	JOSEPH TAMUNOPRINYE OGOLO
Credential	:	NP
Telephone Number	:	469-237-0381

Provider Enumeration Date	:	06/17/2026
Last Update Date	:	06/17/2026

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