Provider Demographics
NPI:1386183283
Name:BLUE HERON PSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:BLUE HERON PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:410-934-7826
Mailing Address - Street 1:774 FAIRVIEW AVE
Mailing Address - Street 2:APT C
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-2956
Mailing Address - Country:US
Mailing Address - Phone:410-934-7826
Mailing Address - Fax:410-934-7826
Practice Address - Street 1:774 FAIRVIEW AVE
Practice Address - Street 2:APT C
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-2956
Practice Address - Country:US
Practice Address - Phone:410-934-7826
Practice Address - Fax:410-934-7826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04511103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty