Provider Demographics
NPI:1578117990
Name:BLUE PEARL WELLNESS, PLLC
Entity Type:Organization
Organization Name:BLUE PEARL WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MANJULA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZA-EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-200-6061
Mailing Address - Street 1:13116 BALFOUR AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1701
Mailing Address - Country:US
Mailing Address - Phone:248-200-6061
Mailing Address - Fax:
Practice Address - Street 1:17344 W 12 MILE RD STE 205
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-6321
Practice Address - Country:US
Practice Address - Phone:248-990-2722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty