Provider Demographics
NPI:1669843561
Name:BIRCH RIVER WELLNESS, P.C.
Entity Type:Organization
Organization Name:BIRCH RIVER WELLNESS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:312-203-3405
Mailing Address - Street 1:4633 N WESTERN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2181
Mailing Address - Country:US
Mailing Address - Phone:312-203-3405
Mailing Address - Fax:
Practice Address - Street 1:4633 N WESTERN AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2181
Practice Address - Country:US
Practice Address - Phone:312-203-3405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-18
Last Update Date:2015-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490097541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty