Provider Demographics
NPI:1194230888
Name:BLUE WATER SPEECH THERAPY
Entity Type:Organization
Organization Name:BLUE WATER SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:251-767-2597
Mailing Address - Street 1:7950 CABERFAE TRL
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3707
Mailing Address - Country:US
Mailing Address - Phone:251-767-2597
Mailing Address - Fax:
Practice Address - Street 1:7950 CABERFAE TRL
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-3707
Practice Address - Country:US
Practice Address - Phone:251-767-2597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005105261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation