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General NPI Number Information
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NPI Number | 1861284267
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Entity Type | Organization
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Legal Business Name | BLUE WATER HEALING CLINIC LLC
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Dates
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Enumeration Date | 05/21/2025
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Last Update Date | 05/21/2025
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Provider Practice Location Address
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Address Line | 1902 4TH ST
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City | JACKSON
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State | MI
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Zip | 49203-4040
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Country | US
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Telephone | 734-273-9681
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Fax |
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Provider Business Mailing Address
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Address Line | 2902 LITTLE ST
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City | PORT HURON
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State | MI
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Zip | 48060-6829
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | AMITA APONTE
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Credential |
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Telephone | 810-937-6259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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