Provider Demographics
NPI:1639912355
Name:BURNS, MISTY GERMAINE
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:GERMAINE
Last Name:BURNS
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 1:2700 AMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3557
Mailing Address - Country:US
Mailing Address - Phone:314-898-5693
Mailing Address - Fax:
Practice Address - Street 1:2700 AMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62221-3557
Practice Address - Country:US
Practice Address - Phone:314-898-5693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor