Provider Demographics
NPI:1679781710
Name:FELLOWES, BRIGHT (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRIGHT
Middle Name:
Last Name:FELLOWES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0909
Mailing Address - Country:US
Mailing Address - Phone:847-566-0164
Mailing Address - Fax:847-566-0375
Practice Address - Street 1:201 E PARK ST
Practice Address - Street 2:UNIT B
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1973
Practice Address - Country:US
Practice Address - Phone:847-566-0164
Practice Address - Fax:847-566-0375
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical