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General NPI Number Information
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NPI Number | 1659878742
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Entity Type | Organization
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Legal Business Name | SILVER BIRCH THERAPY PLLC
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Dates
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Enumeration Date | 04/06/2018
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Last Update Date | 06/02/2021
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Provider Practice Location Address
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Address Line | 905 STANLEY AVE
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City | CLOQUET
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State | MN
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Zip | 55720-3186
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Country | US
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Telephone | 612-876-6586
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Fax | 185-851-5862
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Provider Business Mailing Address
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Address Line | 9450 SW GEMINI DR PMB 14034
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City | BEAVERTON
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State | OR
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Zip | 97008-5842
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Country | US
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Telephone | 612-876-6586
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMY VREDENBURGH
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Credential | MA, LMFT
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Telephone | 612-876-6586
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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 | 2962
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License Number State | MN
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