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General NPI Number Information
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NPI Number | 1124602719
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Entity Type | Organization
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Legal Business Name | BLUE HARBOR COUNSELING SERVICES, L.L.C.
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Dates
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Enumeration Date | 05/10/2021
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Last Update Date | 01/25/2023
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Provider Practice Location Address
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Address Line | 1617 25TH AVE # 203
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City | GULFPORT
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State | MS
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Zip | 39501-2834
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Country | US
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Telephone | 228-255-8553
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7707
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City | DIBERVILLE
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State | MS
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Zip | 39540-7602
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Country | US
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Telephone | 228-325-5855
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | VICKI ARLENE BLAIZE
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Credential | LCSW
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Telephone | 228-325-5855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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