Provider Demographics
NPI:1952878878
Name:BURSON, EMMA (CP60822709)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:BURSON
Suffix:
Gender:F
Credentials:CP60822709
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 N COWICHE RD
Mailing Address - Street 2:
Mailing Address - City:TIETON
Mailing Address - State:WA
Mailing Address - Zip Code:98947-9613
Mailing Address - Country:US
Mailing Address - Phone:509-379-0840
Mailing Address - Fax:509-248-4790
Practice Address - Street 1:600 SUPERIOR LN
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1623
Practice Address - Country:US
Practice Address - Phone:509-853-4108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60822709101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)