Healthcare Provider Details

I. General information

NPI: 1720560832
Provider Name (Legal Business Name): BLUE SKIES PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3495 LAKESIDE DR # 1093
RENO NV
89509-4841
US

IV. Provider business mailing address

1900 NE 3RD ST STE 106-1019
BEND OR
97701-3894
US

V. Phone/Fax

Practice location:
  • Phone: 775-297-8855
  • Fax:
Mailing address:
  • Phone: 775-297-8855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SEAN DODGE
Title or Position: OWNER
Credential: PSYD
Phone: 775-297-8855