Provider Demographics
NPI:1770047680
Name:BLUE, XAVIER
Entity Type:Individual
Prefix:
First Name:XAVIER
Middle Name:
Last Name:BLUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 QUAIL DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5504
Mailing Address - Country:US
Mailing Address - Phone:678-814-7371
Mailing Address - Fax:
Practice Address - Street 1:3737 N SHELTON SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-9105
Practice Address - Country:US
Practice Address - Phone:678-814-7371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)