Provider Demographics
NPI:1003490590
Name:BLUE LIBELULA INC
Entity Type:Organization
Organization Name:BLUE LIBELULA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUADALUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:805-701-9894
Mailing Address - Street 1:PO BOX 865
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-0865
Mailing Address - Country:US
Mailing Address - Phone:818-579-2156
Mailing Address - Fax:541-239-5506
Practice Address - Street 1:2509 1ST ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-2301
Practice Address - Country:US
Practice Address - Phone:818-579-2156
Practice Address - Fax:541-239-5506
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE LIBELULA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-10
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty