MEDICARE: BLUEPRINT BEHAVIORAL HEALTH THERAPY

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1982472841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEPRINT BEHAVIORAL HEALTH THERAPY

Provider Business Mailing Address
First Line	:	1960 E RENEE DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-3062
Country	:	US
Telephone Number	:	405-657-7433
Fax Number	:

Provider Business Practice Location Address
First Line	:	1960 E RENEE DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-3062
Country	:	US
Telephone Number	:	405-657-7433
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	MR. LOUIS ALEXANDER MARULL
Credential	:	LBA, BCBA
Telephone Number	:	405-657-7433

Provider Enumeration Date	:	12/19/2023
Last Update Date	:	12/19/2023

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