Provider Demographics
NPI:1598221996
Name:BRIGHTHOUSE DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:BRIGHTHOUSE DIAGNOSTICS, LLC
Other - Org Name:BRIGHTHOUSE DIAGNOSTICS AND TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAIRA
Authorized Official - Middle Name:ASLAM
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-799-8939
Mailing Address - Street 1:2919 N SOUTHPORT AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7387
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2919 N SOUTHPORT AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-7387
Practice Address - Country:US
Practice Address - Phone:920-474-5044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-11
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty