1386863793 NPI number — BIRCH LAKE PROFESSIONAL COUNSELING GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386863793 NPI number — BIRCH LAKE PROFESSIONAL COUNSELING GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIRCH LAKE PROFESSIONAL COUNSELING GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386863793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 HIGHWAY 96 E
Provider Second Line Business Mailing Address:
SUITE 104B
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-3624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-653-1925
Provider Business Mailing Address Fax Number:
651-653-1956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 HIGHWAY 96 E
Provider Second Line Business Practice Location Address:
SUITE 104B
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110-3624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-653-1925
Provider Business Practice Location Address Fax Number:
651-653-1956
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLADDEN
Authorized Official First Name:
JOE
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
651-653-1925

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  00133 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00133 . This is a "LPC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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