Provider Demographics
NPI:1508929464
Name:BURDESHAW, PATRICIA (M,ED, LPC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BURDESHAW
Suffix:
Gender:F
Credentials:M,ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4572 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2546
Mailing Address - Country:US
Mailing Address - Phone:330-493-4220
Mailing Address - Fax:330-493-8850
Practice Address - Street 1:4572 DRESSLER RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2546
Practice Address - Country:US
Practice Address - Phone:330-493-4220
Practice Address - Fax:330-493-8850
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC5440101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000130008OtherANTHEM