Provider Demographics
NPI:1831233097
Name:BURNHAM, LAURA ELLEN (MA, LPC, LCAS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ELLEN
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:MA, LPC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 RAEFORD RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5098
Mailing Address - Country:US
Mailing Address - Phone:910-689-3524
Mailing Address - Fax:910-401-1926
Practice Address - Street 1:2529 RAEFORD RD
Practice Address - Street 2:SUITE C
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5098
Practice Address - Country:US
Practice Address - Phone:910-689-3524
Practice Address - Fax:910-401-1926
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC61047787Medicaid