Provider Demographics
NPI:1326164070
Name:BURGESS, VANESSA
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2526
Mailing Address - Country:US
Mailing Address - Phone:843-317-4089
Mailing Address - Fax:843-317-4089
Practice Address - Street 1:1104 LOMBARDY ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571
Practice Address - Country:US
Practice Address - Phone:843-431-1100
Practice Address - Fax:843-431-1103
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC3337Medicare ID - Type Unspecified