Provider Demographics
NPI: | 1780028787 |
---|---|
Name: | BLUE HORIZON |
Entity Type: | Organization |
Organization Name: | BLUE HORIZON |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | THERAPIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOSEPH |
Authorized Official - Middle Name: | PHILIP |
Authorized Official - Last Name: | SMITHSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LMSW |
Authorized Official - Phone: | 906-322-6277 |
Mailing Address - Street 1: | 501 W HARRIE ST |
Mailing Address - Street 2: | |
Mailing Address - City: | NEWBERRY |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49868-1226 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 501 W HARRIE ST |
Practice Address - Street 2: | |
Practice Address - City: | NEWBERRY |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49868-1226 |
Practice Address - Country: | US |
Practice Address - Phone: | 906-322-6277 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-04-20 |
Last Update Date: | 2013-04-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 6801086974 | 251S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 1770635427 | Other | NPI - INDIVIDUAL |