Provider Demographics
NPI:1568900355
Name:BLUE DOOR THERAPEUTICS
Entity Type:Organization
Organization Name:BLUE DOOR THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-380-5757
Mailing Address - Street 1:7272 E INDIAN SCHOOL RD
Mailing Address - Street 2:STE 540
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3921
Mailing Address - Country:US
Mailing Address - Phone:602-380-5757
Mailing Address - Fax:
Practice Address - Street 1:10900 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 609
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5216
Practice Address - Country:US
Practice Address - Phone:602-380-5757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC14265101YP2500X
AZ03739175F00000X
AZ31260207P00000X
AZ3111207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty