Provider Demographics
NPI:1053482638
Name:BIRCH, JEREMY DIXON (PHD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DIXON
Last Name:BIRCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:PUTNEY
Mailing Address - State:VT
Mailing Address - Zip Code:05346-9392
Mailing Address - Country:US
Mailing Address - Phone:802-257-9468
Mailing Address - Fax:
Practice Address - Street 1:73 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-3909
Practice Address - Country:US
Practice Address - Phone:802-257-9468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000049103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006514Medicaid
VTVT6514Medicare ID - Type Unspecified