Provider Demographics
NPI:1104298108
Name:BLUE WATERS COUNSELING
Entity type:Organization
Organization Name:BLUE WATERS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:334-792-6736
Mailing Address - Street 1:6501 US HIGHWAY 431 N
Mailing Address - Street 2:P O BOX 321
Mailing Address - City:HEADLAND
Mailing Address - State:AL
Mailing Address - Zip Code:36345-5657
Mailing Address - Country:US
Mailing Address - Phone:334-792-6736
Mailing Address - Fax:
Practice Address - Street 1:6501 US HIGHWAY 431 N
Practice Address - Street 2:
Practice Address - City:HEADLAND
Practice Address - State:AL
Practice Address - Zip Code:36345-5657
Practice Address - Country:US
Practice Address - Phone:334-792-6736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3201101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty