MEDICARE: BIRCH TRAIL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1639797483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRCH TRAIL, LLC

Provider Business Mailing Address
First Line	:	600 WASHINGTON ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4235
Country	:	US
Telephone Number	:	505-718-2472
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 PLAZA ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-3433
Country	:	US
Telephone Number	:	505-426-7052
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MELISSA WILLIAMSON
Credential	:	LCSW
Telephone Number	:	505-718-2472

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	08/01/2020

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Directions to “BIRCH TRAIL, LLC ” Practice Location

Language	Start Address	Practice Location

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