=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467024877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACKBIRD PSYCHOTHERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2021
-----------------------------------------------------
Last Update Date | 07/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 N JACKSON ST STE 100
-----------------------------------------------------
City | JANESVILLE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53548-2952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-631-0911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3521 EAGLES RIDGE DR
-----------------------------------------------------
City | BELOIT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53511-9108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-290-9841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALICIA OCZUS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 608-631-0911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------