Provider Demographics
NPI:1679204267
Name:BIRCH, STEPHANIE (ATC, EMT-B)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BIRCH
Suffix:
Gender:F
Credentials:ATC, EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 PEQUOT AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4498
Mailing Address - Country:US
Mailing Address - Phone:860-701-3518
Mailing Address - Fax:
Practice Address - Street 1:437 PEQUOT AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4498
Practice Address - Country:US
Practice Address - Phone:860-701-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007199146N00000X
CT0004112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic