Provider Demographics
NPI:1437907086
Name:BLUE HERON WELLNESS, LLC
Entity type:Organization
Organization Name:BLUE HERON WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LPC
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:CAROLINE
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:715-229-3019
Mailing Address - Street 1:515 S BARSTOW ST STE 117
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-2618
Mailing Address - Country:US
Mailing Address - Phone:715-229-3019
Mailing Address - Fax:715-229-3268
Practice Address - Street 1:515 S BARSTOW ST STE 117
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-2618
Practice Address - Country:US
Practice Address - Phone:715-229-3019
Practice Address - Fax:715-229-3268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-08
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty