Provider Demographics
NPI:1417240441
Name:BURDICK-DENHAM, ANITA ESTELLE (LPCC)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:ESTELLE
Last Name:BURDICK-DENHAM
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 COUNTRY CLUB RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2484
Mailing Address - Country:US
Mailing Address - Phone:614-501-7337
Mailing Address - Fax:
Practice Address - Street 1:1021 COUNTRY CLUB RD UNIT A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2484
Practice Address - Country:US
Practice Address - Phone:614-501-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 106H00000X, 225400000X, 372600000X
OHE.1901246101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR372600000XMedicaid