Provider Demographics
NPI:1790563740
Name:BLUE LEAF THERAPY
Entity Type:Organization
Organization Name:BLUE LEAF THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:CHOATE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:717-609-3626
Mailing Address - Street 1:1045 S NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1216
Mailing Address - Country:US
Mailing Address - Phone:717-609-3626
Mailing Address - Fax:
Practice Address - Street 1:1828 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-2654
Practice Address - Country:US
Practice Address - Phone:863-272-9633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)