Provider Demographics
NPI:1326298480
Name:BLUE, LIDA ROSANNE (LMT)
Entity Type:Individual
Prefix:
First Name:LIDA
Middle Name:ROSANNE
Last Name:BLUE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 TITTABAWASSEE RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-9431
Mailing Address - Country:US
Mailing Address - Phone:989-790-3476
Mailing Address - Fax:989-393-6187
Practice Address - Street 1:1814 TITTABAWASSEE RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9431
Practice Address - Country:US
Practice Address - Phone:989-790-3476
Practice Address - Fax:989-393-6187
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI7501003428225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)