Healthcare Provider Details

I. General information

NPI: 1861284267
Provider Name (Legal Business Name): BLUE WATER HEALING CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 4TH ST
JACKSON MI
49203-4040
US

IV. Provider business mailing address

2902 LITTLE ST
PORT HURON MI
48060-6829
US

V. Phone/Fax

Practice location:
  • Phone: 734-273-9681
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: AMITA APONTE
Title or Position: CEO
Credential:
Phone: 810-937-6259