Organization
BIRCH BEHAVIORAL MEDICINE, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SUSAN M BAILEY CNP (CERTIFIED NURSE PRACTITIONER)
(651) 905-3858
Entity
Organization
Contact information
Practice address
1310 HIGHWAY 96 E STE 104A, WHITE BEAR LAKE, MN 55110-3618
(651) 905-3858
Mailing address
1310 HIGHWAY 96 E STE 104A, WHITE BEAR LAKE, MN 55110-3618
(651) 905-3858
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6130789
STATE TAX ID
MN
Enumeration date
04/01/2019
Last updated
05/13/2019
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