Provider Demographics
NPI:1265784037
Name:BURGESS, STACHA N
Entity type:Individual
Prefix:
First Name:STACHA
Middle Name:N
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CENTRAL AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3079
Mailing Address - Country:US
Mailing Address - Phone:843-789-4464
Mailing Address - Fax:843-970-2411
Practice Address - Street 1:108 CENTRAL AVE STE 3
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-3079
Practice Address - Country:US
Practice Address - Phone:843-789-4464
Practice Address - Fax:843-970-2411
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6073101Y00000X
SCLPCI-5514101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid
SC1265784037Medicaid