Healthcare Provider Details

I. General information

NPI: 1407770324
Provider Name (Legal Business Name): BLUE HERON THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N BROADWAY AVE STE 235
WICHITA KS
67202-2300
US

IV. Provider business mailing address

200 N BROADWAY AVE STE 235
WICHITA KS
67202-2300
US

V. Phone/Fax

Practice location:
  • Phone: 316-247-4737
  • Fax:
Mailing address:
  • Phone: 316-247-4737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ELLEN TERAN
Title or Position: OWNER
Credential: LSCSW
Phone: 316-247-4737