Provider Demographics
NPI:1902565948
Name:BLU HAVEN WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:BLU HAVEN WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:301-824-9890
Mailing Address - Street 1:3520 SUGARLOAF PARKWAY
Mailing Address - Street 2:F 03-66
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704
Mailing Address - Country:US
Mailing Address - Phone:301-824-9890
Mailing Address - Fax:
Practice Address - Street 1:3520 SUGARLOAF PARKWAY
Practice Address - Street 2:F 03-66
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704
Practice Address - Country:US
Practice Address - Phone:301-824-9890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty