Provider Demographics
NPI:1679622179
Name:BURGESS, ANGELA C (LPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:C
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-3418
Mailing Address - Country:US
Mailing Address - Phone:252-209-0388
Mailing Address - Fax:252-209-0488
Practice Address - Street 1:411 MAIN ST W
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-3321
Practice Address - Country:US
Practice Address - Phone:252-862-4411
Practice Address - Fax:252-862-4414
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2246101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107280Medicaid
NC142CCOtherBC BS