Provider Demographics
NPI:1558494633
Name:BLUE WATER CENTER FOR CHRISTIAN COUNSELING P.C.
Entity Type:Organization
Organization Name:BLUE WATER CENTER FOR CHRISTIAN COUNSELING P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LUNDBLAD
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW ACSW
Authorized Official - Phone:810-985-7380
Mailing Address - Street 1:824 HURON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3705
Mailing Address - Country:US
Mailing Address - Phone:810-985-7380
Mailing Address - Fax:810-985-3074
Practice Address - Street 1:824 HURON AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3705
Practice Address - Country:US
Practice Address - Phone:810-985-7380
Practice Address - Fax:810-985-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801016861101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty