Basic Information
| Provider Information | |||||||||
| NPI: | 1063871432 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIGHTSIDE LCSW SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3715 UNION RD | ||||||||
| Address2: | |||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167830407 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3715 UNION RD | ||||||||
| Address2: | SWEET 122 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167830407 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | FANARA | ||||||||
| AuthorizedOfficialFirstName: | CHARMAINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 7167830407 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 004189 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.