Individual
STACHA N BURGESS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
108 CENTRAL AVE STE 3, GOOSE CREEK, SC 29445-3079
(843) 789-4464
(843) 970-2411
Mailing address
108 CENTRAL AVE STE 3, GOOSE CREEK, SC 29445-3079
(843) 789-4464
(843) 970-2411
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
6073
SC
101YM0800X
Mental Health Counselor
LPCI-5514
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1265784037
—
SC
05
—
1760596480
—
SC
Enumeration date
10/04/2012
Last updated
06/15/2016
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