Provider Demographics
NPI:1619221207
Name:BURCH, DERRICK CHARLES (BHRS)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:CHARLES
Last Name:BURCH
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 S 130TH EAST AVE APT 714B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-1110
Mailing Address - Country:US
Mailing Address - Phone:918-938-8712
Mailing Address - Fax:
Practice Address - Street 1:4112 S 130TH EAST AVE APT 714B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-1110
Practice Address - Country:US
Practice Address - Phone:918-938-8712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-03
Last Update Date:2012-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health