Provider Demographics
NPI:1811587199
Name:BLUE CHANNEL THERAPY
Entity Type:Organization
Organization Name:BLUE CHANNEL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGENECKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:720-295-7548
Mailing Address - Street 1:5460 WARD RD STE 150
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-1828
Mailing Address - Country:US
Mailing Address - Phone:720-295-7548
Mailing Address - Fax:
Practice Address - Street 1:5460 WARD RD STE 150
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-1828
Practice Address - Country:US
Practice Address - Phone:720-295-7548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-21
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty