Provider Demographics
NPI:1740410273
Name:BIRCH, SANDRA W (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:W
Last Name:BIRCH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 494
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:VT
Mailing Address - Zip Code:05152-0494
Mailing Address - Country:US
Mailing Address - Phone:802-430-8470
Mailing Address - Fax:
Practice Address - Street 1:12 BAKER FARM RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05254
Practice Address - Country:US
Practice Address - Phone:802-430-8470
Practice Address - Fax:802-430-8470
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900012771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical