MEDICARE: BEIGE BLACKBIRD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1548957673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEIGE BLACKBIRD LLC

Provider Business Mailing Address
First Line	:	2521 HACKBERRY ST APT 6
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-2143
Country	:	US
Telephone Number	:	513-207-2777
Fax Number	:

Provider Business Practice Location Address
First Line	:	2521 HACKBERRY ST APT 6
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-2143
Country	:	US
Telephone Number	:	513-207-2777
Fax Number	:

Authorized Official
Title or Position	:	OWNER AND CLINICIAN
Name	:	MS. MICAIAH DANIELLE COPELAND
Credential	:	MA
Telephone Number	:	513-207-2777

Provider Enumeration Date	:	04/19/2023
Last Update Date	:	04/19/2023

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