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General NPI Number Information
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NPI Number | 1710633185
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Entity Type | Organization
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Legal Business Name | BLUE RIVER PSYCHIATRY NP PLLC
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Dates
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Enumeration Date | 02/24/2022
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Last Update Date | 03/14/2024
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Provider Practice Location Address
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Address Line | 369 WASHINGTON AVE
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City | KINGSTON
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State | NY
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Zip | 12401-3701
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Country | US
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Telephone | 914-401-0008
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Fax | 914-401-0009
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Provider Business Mailing Address
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Address Line | 369 WASHINGTON AVE STE 1A
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City | KINGSTON
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State | NY
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Zip | 12401-3701
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Country | US
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Telephone | 914-401-0008
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Fax | 914-401-0009
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Authorized Official
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Title or Position | PRACTITIONER
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Name | MINA JOHNSON
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Credential |
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Telephone | 914-401-0008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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