MEDICARE: BLUE HERON COUNSELING LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1790491868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE HERON COUNSELING LLC

Provider Business Mailing Address
First Line	:	113 SCENIC RIDGE RD
Second Line	:
City	:	INGRAM
State	:	TX
Zip	:	78025-5549
Country	:	US
Telephone Number	:	830-715-5483
Fax Number	:	830-217-2348

Provider Business Practice Location Address
First Line	:	113 SCENIC RIDGE RD
Second Line	:
City	:	INGRAM
State	:	TX
Zip	:	78025-5549
Country	:	US
Telephone Number	:	830-715-5483
Fax Number	:	830-217-2348

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	ROBYN SYBIL ADKINS
Credential	:
Telephone Number	:	512-970-0176

Provider Enumeration Date	:	01/23/2023
Last Update Date	:	05/24/2024

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