MEDICARE: BLUEBIRD AVENUE ART THERAPY AND COUNSELING, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	252Y00000X	Early Intervention Provider Agency
2	261QM0850X	Adult Mental Health Clinic/Center
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1841897808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBIRD AVENUE ART THERAPY AND COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	6901 FOLGER DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28270-5947
Country	:	US
Telephone Number	:	704-942-7888
Fax Number	:

Provider Business Practice Location Address
First Line	:	6901 FOLGER DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28270-5947
Country	:	US
Telephone Number	:	704-942-7888
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MS. AMY JILL SEITLIN
Credential	:	ATR-P, LCMHCA
Telephone Number	:	704-942-8888

Provider Enumeration Date	:	10/02/2020
Last Update Date	:	10/02/2020

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