Basic Information
| Provider Information | |||||||||
| NPI: | 1023415072 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE WATER SERENITY COUNSELING PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5429 SHOREWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103571725 | ||||||||
| FaxNumber: | 8108244865 | ||||||||
| Practice Location | |||||||||
| Address1: | 5429 SHOREWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103571725 | ||||||||
| FaxNumber: | 8108244865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2014 | ||||||||
| LastUpdateDate: | 12/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | ALEXIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER AND SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 8108244865 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW,CADC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1609118637 | 01 | MI | NATIONAL PROVIDER IDENTIFICATION | OTHER |