Provider Demographics
NPI:1710743521
Name:BRIGHT SHADOWS TELEPSYCHIATRY SERVICES, PLLC
Entity Type:Organization
Organization Name:BRIGHT SHADOWS TELEPSYCHIATRY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONDESHYA
Authorized Official - Middle Name:KEYONNA
Authorized Official - Last Name:COSBY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:252-751-5103
Mailing Address - Street 1:PO BOX 9244
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23670-0244
Mailing Address - Country:US
Mailing Address - Phone:252-751-5103
Mailing Address - Fax:
Practice Address - Street 1:4410 CLAIBORNE SQ E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2071
Practice Address - Country:US
Practice Address - Phone:252-751-5103
Practice Address - Fax:252-751-5127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty