MEDICARE: ELISE VICTORIA BIRCH MA-AT, LMHCA, ATR-P

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	221700000X	Art Therapist	20-022
2	101YM0800X	Mental Health Counselor	88001096A	IN

General Provider Information

NPI Number	:	1649882093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISE VICTORIA BIRCH MA-AT, LMHCA, ATR-P

Provider Business Mailing Address
First Line	:	6411 S EAST ST STE A
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-2737
Country	:	US
Telephone Number	:	317-780-5750
Fax Number	:	317-780-5755

Provider Business Practice Location Address
First Line	:	6411 S EAST ST STE A
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-2737
Country	:	US
Telephone Number	:	317-780-5750
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2020
Last Update Date	:	08/18/2020

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