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General NPI Number Information
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NPI Number | 1104276880
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Entity Type | Individual
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Provider Name | LIESE FREDERICKA VON BRAUCHITSCH MA, LMFT
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Gender | Female
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Dates
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Enumeration Date | 06/14/2016
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Last Update Date | 05/06/2019
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Provider Practice Location Address
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Address Line | 2900 PIEDMONT AVE 2900 PIEDMONT AVE
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City | DULUTH
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State | MN
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Zip | 55811-2915
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Country | US
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Telephone | 218-740-7618
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Fax |
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Provider Business Mailing Address
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Address Line | 4720 BURNING TREE ROAD BURCH TREE CENTER
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City | DULUTH
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State | MN
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Zip | 55811
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Country | US
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Telephone | 218-623-1812
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Fax | 218-623-1811
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 2705
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License Number State | MN
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