# BLUE HERON WELLNESS LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679063424
- **Authorized official:** RENEA CHRISTINE MABLE LISW-CP (OWNER)
- **Authorized official phone:** (803) 429-9065

## Contact information

- **Practice address:** 719 S LAKE DR, LEXINGTON, SC 29072-3432
- **Practice address phone:** (803) 609-7792
- **Practice address fax:** (803) 816-9058
- **Mailing address:** 419 FIREBRIDGE DR, CHAPIN, SC 29036-7639
- **Mailing address phone:** (803) 429-9065

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1041C0700X | Clinical Social Worker | 10640 | SC | Yes |

## Other

- **Enumeration date:** 05/17/2018
- **Last updated:** 07/20/2021