Basic Information
| Provider Information | |||||||||
| NPI: | 1083804470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUSH (MAIDEN | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT ROAD, NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 GLENLAKE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706777389 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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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 | 101YP2500X | LPC005298 | GA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 164W00000X | LPN061159 | GA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.