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General NPI Number Information
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NPI Number | 1003490590
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Entity Type | Organization
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Legal Business Name | BLUE LIBELULA INC
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Dates
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Enumeration Date | 05/10/2021
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Last Update Date | 02/07/2024
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Provider Practice Location Address
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Address Line | 2509 1ST ST
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City | BAKER CITY
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State | OR
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Zip | 97814-2301
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Country | US
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Telephone | 818-579-2156
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Fax | 541-239-5506
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Provider Business Mailing Address
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Address Line | PO BOX 865
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City | BAKER CITY
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State | OR
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Zip | 97814-0865
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Country | US
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Telephone | 818-579-2156
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Fax | 541-239-5506
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Authorized Official
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Title or Position | PRESIDENT / OWNER
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Name | GUADALUPE KIRKLIN
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Credential | LMFT
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Telephone | 805-701-9894
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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