Provider Demographics
NPI:1619333788
Name:EARTHSONG INTEGRATIVE MEDICINE AND MIDWIFERY, LLC
Entity Type:Organization
Organization Name:EARTHSONG INTEGRATIVE MEDICINE AND MIDWIFERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VAN DE WATER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CNM
Authorized Official - Phone:907-957-6597
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:SOUTH EGREMONT
Mailing Address - State:MA
Mailing Address - Zip Code:01258-0006
Mailing Address - Country:US
Mailing Address - Phone:907-957-6597
Mailing Address - Fax:833-689-9875
Practice Address - Street 1:1601 SALMON CREEK LN
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7867
Practice Address - Country:US
Practice Address - Phone:907-957-6597
Practice Address - Fax:833-689-9875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK983261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1022737Medicaid