Basic Information
| Provider Information | |||||||||
| NPI: | 1033418082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURCH | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MA, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 461 W HURON ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484561991 | ||||||||
| FaxNumber: | 2484568151 | ||||||||
| Practice Location | |||||||||
| Address1: | 461 W HURON ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484561991 | ||||||||
| FaxNumber: | 2484568151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 11/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 6301014036 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |