MEDICARE: THE VIRTUAL COUCH THERAPY PRACTICE

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	:	1639987225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE VIRTUAL COUCH THERAPY PRACTICE

Provider Business Mailing Address
First Line	:	9018 BUR OAK CT
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55129-1807
Country	:	US
Telephone Number	:	516-505-5347
Fax Number	:

Provider Business Practice Location Address
First Line	:	9018 BUR OAK CT
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55129-1807
Country	:	US
Telephone Number	:	651-505-5347
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	KELSEY PLACE
Credential	:	LICSW
Telephone Number	:	651-505-5347

Provider Enumeration Date	:	12/27/2024
Last Update Date	:	01/01/2025

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