Provider Demographics
NPI:1588830905
Name:BURGESS COUNSELING & MEDIATION SERVICES
Entity Type:Organization
Organization Name:BURGESS COUNSELING & MEDIATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHP
Authorized Official - Phone:402-746-4141
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:757 HWY 281 SUITE 4
Mailing Address - City:RED CLOUD
Mailing Address - State:NE
Mailing Address - Zip Code:68970-0383
Mailing Address - Country:US
Mailing Address - Phone:402-746-4141
Mailing Address - Fax:
Practice Address - Street 1:757 HWY 281
Practice Address - Street 2:SUITE 4
Practice Address - City:RED CLOUD
Practice Address - State:NE
Practice Address - Zip Code:68970
Practice Address - Country:US
Practice Address - Phone:402-746-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2991101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025623300Medicaid