Provider Demographics
NPI:1801252515
Name:BLUE WAVE COUNSELING
Entity type:Organization
Organization Name:BLUE WAVE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:321-313-1745
Mailing Address - Street 1:330 N BABCOCK ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-7324
Mailing Address - Country:US
Mailing Address - Phone:321-313-1745
Mailing Address - Fax:321-428-3358
Practice Address - Street 1:330 N BABCOCK ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-7324
Practice Address - Country:US
Practice Address - Phone:321-313-1745
Practice Address - Fax:321-428-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH-9263101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001041900Medicaid