Provider Demographics
NPI:1811311517
Name:BLUE WATER BEHAVIORAL CONSULTING LLC
Entity type:Organization
Organization Name:BLUE WATER BEHAVIORAL CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LBA, BCBA
Authorized Official - Phone:360-333-5684
Mailing Address - Street 1:1777 S. BURLINGTON BLVD
Mailing Address - Street 2:#465
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233
Mailing Address - Country:US
Mailing Address - Phone:360-333-5684
Mailing Address - Fax:360-230-3272
Practice Address - Street 1:851 SE PIONEER WAY
Practice Address - Street 2:201
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277
Practice Address - Country:US
Practice Address - Phone:360-333-5684
Practice Address - Fax:360-230-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-16
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 251S00000X
1-10-7191251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041449Medicaid