Healthcare Provider Details

I. General information

NPI: 1619675337
Provider Name (Legal Business Name): BLUE ASPEN COUNSELING AND CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 PARK ST
MONTCLAIR NJ
07042-3465
US

IV. Provider business mailing address

85 PARK ST
MONTCLAIR NJ
07042-3465
US

V. Phone/Fax

Practice location:
  • Phone: 862-234-0658
  • Fax:
Mailing address:
  • Phone: 862-234-0658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
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
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JUSTINE ASHLEE
Title or Position: OWNER
Credential:
Phone: 862-220-9426