=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902204787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUESPACE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2014
-----------------------------------------------------
Last Update Date | 12/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 149 N CENTER ST SUITE 200
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48167-1486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-880-8684
-----------------------------------------------------
Fax | 734-738-6980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44511 BROADMOOR BLVD
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-8633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-880-8684
-----------------------------------------------------
Fax | 734-738-6980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VICKI L BUCCIERE
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 248-880-8684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801018346
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------