Provider Demographics
NPI:1861286015
Name:BIRCHBARK PLAY THERAPY
Entity type:Organization
Organization Name:BIRCHBARK PLAY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MASTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC-S
Authorized Official - Phone:612-578-2502
Mailing Address - Street 1:6045 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-3109
Mailing Address - Country:US
Mailing Address - Phone:612-578-2502
Mailing Address - Fax:
Practice Address - Street 1:7400 LYNDALE AVE S STE 160
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55423-4142
Practice Address - Country:US
Practice Address - Phone:612-578-2502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1619375250Medicaid