=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568900355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE DOOR THERAPEUTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2017
-----------------------------------------------------
Last Update Date | 02/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10900 N SCOTTSDALE RD SUITE 609
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85254-5216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-380-5757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7272 E INDIAN SCHOOL RD STE 540
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85251-3921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-380-5757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. GINA M BERMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 602-380-5757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC14265
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 03739
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 3111
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 31260
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------