Provider Demographics
NPI:1902204787
Name:BLUESPACE COUNSELING
Entity Type:Organization
Organization Name:BLUESPACE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUCCIERE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-880-8684
Mailing Address - Street 1:44511 BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8633
Mailing Address - Country:US
Mailing Address - Phone:248-880-8684
Mailing Address - Fax:734-738-6980
Practice Address - Street 1:149 N CENTER ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1486
Practice Address - Country:US
Practice Address - Phone:248-880-8684
Practice Address - Fax:734-738-6980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010183461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty