Provider Demographics
NPI:1205962123
Name:BURLISON, AMY D (MED, LPC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:D
Last Name:BURLISON
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MOBILE COUNSELING SERVICES
Mailing Address - Street 2:1039 ACORN HOLLOW COURT
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026
Mailing Address - Country:US
Mailing Address - Phone:314-691-3611
Mailing Address - Fax:636-225-1386
Practice Address - Street 1:MOBILE COUNSELING SERVICES
Practice Address - Street 2:1039 ACORN HOLLOW COURT
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026
Practice Address - Country:US
Practice Address - Phone:314-691-3611
Practice Address - Fax:636-225-1386
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000162585101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494670516Medicaid