| Blue Heron Wellness Llc | |
|
719 S Lake Dr Lexington SC 29072-3432 | |
| (803) 609-7792 | |
| (803) 816-9058 |
| Full Name | Blue Heron Wellness Llc |
|---|---|
| Speciality | Social Worker |
| Location | 719 S Lake Dr, Lexington, South Carolina |
| Authorized Official Name and Position | Renea Christine Mable (OWNER) |
| Authorized Official Contact | 8034299065 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Blue Heron Wellness Llc 419 Firebridge Dr Chapin SC 29036-7639 Ph: (803) 429-9065 | Blue Heron Wellness Llc 719 S Lake Dr Lexington SC 29072-3432 Ph: (803) 609-7792 |
| NPI Number | 1679063424 |
|---|---|
| Provider Enumeration Date | 05/17/2018 |
| Last Update Date | 07/20/2021 |
| Certification Date | 07/20/2021 |
| Medicare PECOS PAC ID | 5698019628 |
|---|---|
| Medicare Enrollment ID | O20181203001586 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1679063424 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | 10640 (South Carolina) | Primary |
| Provider Name | Renea C Mable |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1629568472 PECOS PAC ID: 0941544704 Enrollment ID: I20190205002760 |
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