Provider Demographics
NPI:1598124166
Name:BURGESS, SHANITA
Entity Type:Individual
Prefix:
First Name:SHANITA
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANITA
Other - Middle Name:
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:524 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-8644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:524 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-8644
Practice Address - Country:US
Practice Address - Phone:803-328-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health