Basic Information
| Provider Information | |||||||||
| NPI: | 1578701389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLUE | ||||||||
| FirstName: | FELIPE | ||||||||
| MiddleName: | KHRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCAS-P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 MORREENE RD | ||||||||
| Address2: | APARTMENT 15L | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277054524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436286384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 355 S MADISON BLVD | ||||||||
| Address2: | SUITE C1 | ||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275735485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365998366 | ||||||||
| FaxNumber: | 3363226168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2009 | ||||||||
| LastUpdateDate: | 02/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.