Provider Demographics
NPI:1871854513
Name:BURRISS, MISTY LEE (BSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LEE
Last Name:BURRISS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 COLOMA WAY
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-5614
Mailing Address - Country:US
Mailing Address - Phone:530-383-9049
Mailing Address - Fax:
Practice Address - Street 1:1706 COLOMA WAY
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-383-9049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker