=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629764204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE FEATHER THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2023
-----------------------------------------------------
Last Update Date | 04/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 927 BROOKLINE BLVD STE 1
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15226-2182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-314-1553
-----------------------------------------------------
Fax | 412-314-1559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 927 BROOKLINE BLVD STE 1
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15226-2182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-314-1553
-----------------------------------------------------
Fax | 412-314-1559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | RUSTIN PARADISE
-----------------------------------------------------
Credential | MS LPC
-----------------------------------------------------
Telephone | 412-314-1553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------