MEDICARE: BLUE THEORY 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1992403513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE THEORY COUNSELING LLC

Provider Business Mailing Address
First Line	:	10808 S RIVER FRONT PKWY STE 308
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-5761
Country	:	US
Telephone Number	:	801-984-6728
Fax Number	:	801-984-4715

Provider Business Practice Location Address
First Line	:	10808 S RIVER FRONT PKWY STE 308
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-5761
Country	:	US
Telephone Number	:	801-984-6728
Fax Number	:	801-984-4715

Authorized Official
Title or Position	:	PROVIDER
Name	:	JACOB ANDREASON
Credential	:
Telephone Number	:	801-984-6728

Provider Enumeration Date	:	02/22/2023
Last Update Date	:	03/10/2023

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