Healthcare Provider Details

I. General information

NPI: 1124405055
Provider Name (Legal Business Name): BIRCHWOOD WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6950 NE 14TH ST STE 36
ANKENY IA
50023-8903
US

IV. Provider business mailing address

6950 NE 14TH ST STE 36
ANKENY IA
50023-8903
US

V. Phone/Fax

Practice location:
  • Phone: 515-289-1515
  • Fax: 515-289-1511
Mailing address:
  • Phone: 515-289-1515
  • Fax: 515-289-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number001268
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberG-108504
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MEGAN ELISE OTTO CAVES
Title or Position: LICENSED PSYCHOLOGIST
Credential:
Phone: 515-289-1515