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General NPI Number Information
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NPI Number | 1801338447
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Entity Type | Organization
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Legal Business Name | BLUEWATER BEHAVIORAL SERVICES
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Dates
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Enumeration Date | 11/14/2016
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Last Update Date | 11/02/2017
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Provider Practice Location Address
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Address Line | 4451 PARKWOOD SQ
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City | NICEVILLE
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State | FL
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Zip | 32578-9707
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Country | US
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Telephone | 850-842-9750
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Fax |
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Provider Business Mailing Address
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Address Line | 4451 PARKWOOD SQ
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City | NICEVILLE
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State | FL
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Zip | 32578-9707
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Country | US
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Telephone | 850-842-9750
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Fax |
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Authorized Official
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Title or Position | COOWNER, BUSINESS MANAGER
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Name | JOSE VELASQUEZ
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Credential |
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Telephone | 850-842-9750
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-14-16721
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License Number State | CO
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