Healthcare Provider Details

I. General information

NPI: 1326778747
Provider Name (Legal Business Name): BLUE ANCHOR BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 E BELTLINE AVE SE STE 250
GRAND RAPIDS MI
49506-4364
US

IV. Provider business mailing address

11790 HAYMEADOW CT
RAVENNA MI
49451-9489
US

V. Phone/Fax

Practice location:
  • Phone: 563-542-2850
  • Fax:
Mailing address:
  • Phone: 563-542-2850
  • 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: JESSICA NICOLE MOSKALEWSKI
Title or Position: CLINICAL THERAPIST
Credential: LMSW
Phone: 563-542-2850