Provider Demographics
NPI:1639721673
Name:BIRCH, ISETTA
Entity Type:Individual
Prefix:MRS
First Name:ISETTA
Middle Name:
Last Name:BIRCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 DESOTO AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-4420
Mailing Address - Country:US
Mailing Address - Phone:662-592-5397
Mailing Address - Fax:
Practice Address - Street 1:860 E RIVER PL STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-3442
Practice Address - Country:US
Practice Address - Phone:769-251-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor