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General NPI Number Information
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NPI Number | 1336628478
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Entity Type | Organization
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Legal Business Name | VLW LLC
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Dates
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Enumeration Date | 08/09/2018
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Last Update Date | 11/17/2021
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Provider Practice Location Address
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Address Line | 4255 PHEASANT RIDGE DR NE STE 412
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City | BLAINE
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State | MN
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Zip | 55449-5066
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Country | US
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Telephone | 612-799-6652
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Fax |
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Provider Business Mailing Address
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Address Line | 8578 DUNKIRK CT NE
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City | BLAINE
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State | MN
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Zip | 55449-6789
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Country | US
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Telephone | 612-799-6652
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | AMANDA ADELL WIRTH
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Credential | LMFT
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Telephone | 612-799-6652
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 3061
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License Number State | MN
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