Provider Demographics
NPI:1336628478
Name:VLW LLC
Entity Type:Organization
Organization Name:VLW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:ADELL
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-799-6652
Mailing Address - Street 1:8578 DUNKIRK CT NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6789
Mailing Address - Country:US
Mailing Address - Phone:612-799-6652
Mailing Address - Fax:
Practice Address - Street 1:4255 PHEASANT RIDGE DR NE STE 412
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5066
Practice Address - Country:US
Practice Address - Phone:612-799-6652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3061261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5724462Medicaid