Provider Demographics
NPI:1215377452
Name:BURCH, VIVIAN WATSON (MASTER LEVEL, CAP)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:WATSON
Last Name:BURCH
Suffix:
Gender:F
Credentials:MASTER LEVEL, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-1937
Mailing Address - Country:US
Mailing Address - Phone:904-765-0665
Mailing Address - Fax:
Practice Address - Street 1:435 CLARK RD STE 107
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-5558
Practice Address - Country:US
Practice Address - Phone:904-765-0665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health