Provider Demographics
NPI:1295443224
Name:BLUE WAVE BEHAVIORAL SERIVCES
Entity type:Organization
Organization Name:BLUE WAVE BEHAVIORAL SERIVCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WIXON
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:727-278-6765
Mailing Address - Street 1:1482 PREMIER VILLAGE WAY FL USA
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-2885
Mailing Address - Country:US
Mailing Address - Phone:727-278-6765
Mailing Address - Fax:
Practice Address - Street 1:1482 PREMIER VILLAGE WAY FL USA
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-2885
Practice Address - Country:US
Practice Address - Phone:727-278-6765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110767000Medicaid