Healthcare Provider Details

I. General information

NPI: 1861206583
Provider Name (Legal Business Name): BLUEGREEN COUNSELING & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 MOUNT RUSHMORE RD STE 3-202
RAPID CITY SD
57701-4591
US

IV. Provider business mailing address

1601 MOUNT RUSHMORE RD STE 3-202
RAPID CITY SD
57701-4591
US

V. Phone/Fax

Practice location:
  • Phone: 210-846-9037
  • Fax:
Mailing address:
  • Phone: 210-846-9037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARY ANN FREDRICKSON
Title or Position: CLINICAL SOCIAL WORKER/OWNER
Credential: CSW-PIP
Phone: 210-846-9037