Provider Demographics
NPI:1376846584
Name:BRIGHTSIDE PSYCHOLOGY & INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:BRIGHTSIDE PSYCHOLOGY & INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRERO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:407-601-7748
Mailing Address - Street 1:1277 N SEMORAN BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-3569
Mailing Address - Country:US
Mailing Address - Phone:407-601-7748
Mailing Address - Fax:407-601-7749
Practice Address - Street 1:1277 N SEMORAN BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3569
Practice Address - Country:US
Practice Address - Phone:407-601-7748
Practice Address - Fax:407-601-7749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10506101YM0800X
FLPY7638103TC0700X
FLPY7723103TC0700X
FLPY8298103TC1900X
FLME110882174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty