Provider Demographics
NPI:1093938375
Name:BIRCH, MARY JOSEPHINE (MT-BC, DTS, CIMI)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JOSEPHINE
Last Name:BIRCH
Suffix:
Gender:F
Credentials:MT-BC, DTS, CIMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18W233 KNOLLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3634
Mailing Address - Country:US
Mailing Address - Phone:630-953-2821
Mailing Address - Fax:630-953-9831
Practice Address - Street 1:18W233 KNOLLWOOD LN
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-3634
Practice Address - Country:US
Practice Address - Phone:630-953-2821
Practice Address - Fax:630-953-9831
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILMB49860101P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist