Provider Demographics
NPI:1386863793
Name:BIRCH LAKE PROFESSIONAL COUNSELING GROUP, INC.
Entity Type:Organization
Organization Name:BIRCH LAKE PROFESSIONAL COUNSELING GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GLADDEN
Authorized Official - Suffix:II
Authorized Official - Credentials:PHD LPC, LMHC
Authorized Official - Phone:651-653-1925
Mailing Address - Street 1:1310 HIGHWAY 96 E
Mailing Address - Street 2:SUITE 104B
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3624
Mailing Address - Country:US
Mailing Address - Phone:651-653-1925
Mailing Address - Fax:651-653-1956
Practice Address - Street 1:1310 HIGHWAY 96 E
Practice Address - Street 2:SUITE 104B
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3624
Practice Address - Country:US
Practice Address - Phone:651-653-1925
Practice Address - Fax:651-653-1956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00133101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00133OtherLPC