Provider Demographics
NPI:1033120449
Name:BRIGHT-BERHANNAN, PEGGY L (LCSW-R)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:L
Last Name:BRIGHT-BERHANNAN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CAYUTA AVE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:NY
Mailing Address - Zip Code:14892-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 S PERRY ST
Practice Address - Street 2:STE 4
Practice Address - City:WATKINS GLEN
Practice Address - State:NY
Practice Address - Zip Code:14891-1615
Practice Address - Country:US
Practice Address - Phone:607-535-8282
Practice Address - Fax:607-535-8284
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0494421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07300049442LIMedicaid
NYRB0919Medicare ID - Type Unspecified