=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578167458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEBIRD BEHAVIORAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2020
-----------------------------------------------------
Last Update Date | 11/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2168 CENTER GRANGE DR
-----------------------------------------------------
City | BYRON CENTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49315-9538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-798-0474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 390
-----------------------------------------------------
City | BYRON CENTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49315-0390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BETH ANN BOOGHOLT
-----------------------------------------------------
Credential | MS, LLP, BCBA, LBA
-----------------------------------------------------
Telephone | 248-798-0474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------