Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor | LPC007073 | GA |
NPI | 1003151861 |
---|---|
Provider Name | Misty Burchette |
First Address | Waycross, GA 31503-3823 |
Second Address | Waycross, GA 31503-3823 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2012 |
Last Update Date | 05/12/2012 |