Provider Demographics
NPI:1639797483
Name:BIRCH TRAIL, LLC
Entity Type:Organization
Organization Name:BIRCH TRAIL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-718-2472
Mailing Address - Street 1:600 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4235
Mailing Address - Country:US
Mailing Address - Phone:505-718-2472
Mailing Address - Fax:
Practice Address - Street 1:210 PLAZA ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3433
Practice Address - Country:US
Practice Address - Phone:505-426-7052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-08
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health