=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386109957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE SKY MENTAL HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2019
-----------------------------------------------------
Last Update Date | 12/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14362 107TH ST SE
-----------------------------------------------------
City | BECKER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55308-8905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-831-3715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14362 107TH ST SE
-----------------------------------------------------
City | BECKER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55308-8905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-831-3715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | LESLIE MARIE YOUNG
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 218-831-3715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------