Provider Demographics
NPI:1215348016
Name:BIRCH, DEREK JOHN (BCBA)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JOHN
Last Name:BIRCH
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 RICHARDS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-5236
Mailing Address - Country:US
Mailing Address - Phone:603-208-9359
Mailing Address - Fax:
Practice Address - Street 1:373 S WILLOW ST STE 266
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5751
Practice Address - Country:US
Practice Address - Phone:877-315-8080
Practice Address - Fax:877-345-4009
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid