Healthcare Provider Details

I. General information

NPI: 1295439016
Provider Name (Legal Business Name): BLUE HERON COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 PEACHTREE ST NW STE 510
ATLANTA GA
30309-2462
US

IV. Provider business mailing address

928 SYCAMORE DR
DECATUR GA
30030-1641
US

V. Phone/Fax

Practice location:
  • Phone: 404-797-3292
  • Fax:
Mailing address:
  • Phone: 404-797-3292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. PATRICIA NATANAGARA
Title or Position: OWNER
Credential: LPC
Phone: 404-797-3292