Provider Demographics
NPI:1104276880
Name:VON BRAUCHITSCH, LIESE FREDERICKA (MA, LMFT)
Entity type:Individual
Prefix:MS
First Name:LIESE
Middle Name:FREDERICKA
Last Name:VON BRAUCHITSCH
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 BURNING TREE ROAD
Mailing Address - Street 2:BURCH TREE CENTER
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811
Mailing Address - Country:US
Mailing Address - Phone:218-623-1812
Mailing Address - Fax:218-623-1811
Practice Address - Street 1:2900 PIEDMONT AVE
Practice Address - Street 2:2900 PIEDMONT AVE
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2915
Practice Address - Country:US
Practice Address - Phone:218-740-7618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2705106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist