Provider Demographics
NPI:1477172666
Name:BLUE RIDER EXPRESSIVE THERAPY LLC
Entity Type:Organization
Organization Name:BLUE RIDER EXPRESSIVE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-215-6766
Mailing Address - Street 1:2528 DWIGHT COCHRAN RD
Mailing Address - Street 2:
Mailing Address - City:DUCK RIVER
Mailing Address - State:TN
Mailing Address - Zip Code:38454-3434
Mailing Address - Country:US
Mailing Address - Phone:517-215-6766
Mailing Address - Fax:
Practice Address - Street 1:2528 DWIGHT COCHRAN RD
Practice Address - Street 2:
Practice Address - City:DUCK RIVER
Practice Address - State:TN
Practice Address - Zip Code:38454-3434
Practice Address - Country:US
Practice Address - Phone:517-215-6766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty