Healthcare Provider Details

I. General information

NPI: 1164727954
Provider Name (Legal Business Name): BIRCH GROVE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 RIVER RD N
KEIZER OR
97303-4536
US

IV. Provider business mailing address

4720 RIVER RD N
KEIZER OR
97303-4536
US

V. Phone/Fax

Practice location:
  • Phone: 907-388-4689
  • Fax: 503-318-2212
Mailing address:
  • Phone: 907-388-4689
  • Fax: 503-318-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4684
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: LAURIE HOLLAND-KLEIN
Title or Position: OWNER
Credential: LCSW
Phone: 907-388-4689