Provider Demographics
NPI:1598435265
Name:BLUE HERON THERAPY, LLC
Entity Type:Organization
Organization Name:BLUE HERON THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KATELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:EMMA
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:774-573-6185
Mailing Address - Street 1:165 MAIN ST UNIT 203
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-1584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 MAIN ST UNIT 203
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1584
Practice Address - Country:US
Practice Address - Phone:774-613-0436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty