MEDICARE: BLUE WATERS COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	3201	AL

General Provider Information

NPI Number	:	1104298108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE WATERS COUNSELING

Provider Business Mailing Address
First Line	:	6501 US HIGHWAY 431 N
Second Line	:	P O BOX 321
City	:	HEADLAND
State	:	AL
Zip	:	36345-5657
Country	:	US
Telephone Number	:	334-792-6736
Fax Number	:

Provider Business Practice Location Address
First Line	:	6501 US HIGHWAY 431 N
Second Line	:
City	:	HEADLAND
State	:	AL
Zip	:	36345-5657
Country	:	US
Telephone Number	:	334-792-6736
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ANDREA GODFREY
Credential	:	LPC
Telephone Number	:	334-792-6736

Provider Enumeration Date	:	10/29/2015
Last Update Date	:	10/29/2015

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