Provider Demographics
NPI:1114780533
Name:BLUE PINE PSYCH SERVICES LLC
Entity Type:Organization
Organization Name:BLUE PINE PSYCH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:231-620-6085
Mailing Address - Street 1:19 WATER ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-1104
Mailing Address - Country:US
Mailing Address - Phone:231-620-6085
Mailing Address - Fax:
Practice Address - Street 1:19 WATER ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1104
Practice Address - Country:US
Practice Address - Phone:231-620-6085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1689295412OtherNPI