Provider Demographics
NPI:1871884460
Name:BRIGHTSIDE LCSW SERVICES, PLLC
Entity type:Organization
Organization Name:BRIGHTSIDE LCSW SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FANARA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSWR
Authorized Official - Phone:716-783-0407
Mailing Address - Street 1:59 ALYS DR E
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-1402
Mailing Address - Country:US
Mailing Address - Phone:716-783-0407
Mailing Address - Fax:716-393-3430
Practice Address - Street 1:40 GARDENVILLE PKWY STE 213
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1399
Practice Address - Country:US
Practice Address - Phone:716-783-0407
Practice Address - Fax:716-393-3430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071265-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05054586Medicaid