Basic Information
| Provider Information | |||||||||
| NPI: | 1871884460 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIGHTSIDE LCSW SERVICES, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRIGHTSIDE COUNSELING SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 59 ALYS DR E | ||||||||
| Address2: | |||||||||
| City: | DEPEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140431402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167830407 | ||||||||
| FaxNumber: | 7163933430 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 GARDENVILLE PKWY STE 213 | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142241399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167830407 | ||||||||
| FaxNumber: | 7163933430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2011 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FANARA | ||||||||
| AuthorizedOfficialFirstName: | CHARMAINE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7167830407 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSWR | ||||||||
| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 071265-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 05054586 | 05 | NY | MEDICAID |