Provider Demographics
NPI:1598363673
Name:BLUE BEHAVIORAL THERAPY
Entity Type:Organization
Organization Name:BLUE BEHAVIORAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAYRUS
Authorized Official - Middle Name:ABDIRAHMAN
Authorized Official - Last Name:DUALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-805-1982
Mailing Address - Street 1:10800 LYNDALE AVE S STE 250
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-5690
Mailing Address - Country:US
Mailing Address - Phone:614-805-1982
Mailing Address - Fax:
Practice Address - Street 1:10800 LYNDALE AVE S STE 250
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-5690
Practice Address - Country:US
Practice Address - Phone:614-805-1982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-12
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health