Healthcare Provider Details

I. General information

NPI: 1194258467
Provider Name (Legal Business Name): BLUE STARS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 EDWARD TER APT A
SAINT LOUIS MO
63117-1520
US

IV. Provider business mailing address

1101 EDWARD TER APT A
SAINT LOUIS MO
63117-1520
US

V. Phone/Fax

Practice location:
  • Phone: 314-650-9288
  • Fax:
Mailing address:
  • Phone: 314-650-9288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number2014027319
License Number StateMO

VIII. Authorized Official

Name: MS. BRIDGET MARY HORMBERG
Title or Position: CO-OWNER/CO-FOUNDER
Credential: MOT, OTR/L
Phone: 314-650-9288