Provider Demographics
NPI:1083076467
Name:BURNS, ANDREA (LCPC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W KENWOOD AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6380
Mailing Address - Country:US
Mailing Address - Phone:217-520-1047
Mailing Address - Fax:217-876-2840
Practice Address - Street 1:102 W KENWOOD AVE STE 120A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4368
Practice Address - Country:US
Practice Address - Phone:217-520-1047
Practice Address - Fax:217-520-1047
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010478101YP2500X, 101YP2500X
IL178.010241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370982024-002Medicaid