Healthcare Provider Details

I. General information

NPI: 1760646715
Provider Name (Legal Business Name): BIRCH LAKE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 1ST ST. N.
HACKENSACK MN
56452-0471
US

IV. Provider business mailing address

PO BOX 471
HACKENSACK MN
56452-0471
US

V. Phone/Fax

Practice location:
  • Phone: 218-675-5101
  • Fax: 801-340-9860
Mailing address:
  • Phone: 218-675-5101
  • Fax: 801-340-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. CAROL E. HORSAGER
Title or Position: OWNER
Credential: LMFT
Phone: 218-675-5101