Provider Demographics
NPI:1669055042
Name:BURTH, MARY KATHERINE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:BURTH
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 1:116 FOXGLOVE ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-3463
Mailing Address - Country:US
Mailing Address - Phone:704-345-3753
Mailing Address - Fax:
Practice Address - Street 1:910 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-3449
Practice Address - Country:US
Practice Address - Phone:704-748-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82374225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist