Healthcare Provider Details

I. General information

NPI: 1164967204
Provider Name (Legal Business Name): BLUE LINE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 SW 57TH AVE #225
SOUTH MIAMI FL
33143-5428
US

IV. Provider business mailing address

9800 SW 148TH TER
MIAMI FL
33176-7848
US

V. Phone/Fax

Practice location:
  • Phone: 305-916-6665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMH10663
License Number StateFL

VIII. Authorized Official

Name: MELISSA BAROSELA
Title or Position: LMHC/DIRECTOR
Credential:
Phone: 305-916-6665