MEDICARE: AMANDA LEE BURG LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	304479	MN

General Provider Information

NPI Number	:	1144731001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA LEE BURG LADC

Provider Business Mailing Address
First Line	:	1826 COMMERCE DR
Second Line	:
City	:	NORTH MANKATO
State	:	MN
Zip	:	56003-1800
Country	:	US
Telephone Number	:	507-290-3502
Fax Number	:

Provider Business Practice Location Address
First Line	:	1826 COMMERCE DR
Second Line	:
City	:	NORTH MANKATO
State	:	MN
Zip	:	56003-1800
Country	:	US
Telephone Number	:	507-229-0350
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2017
Last Update Date	:	10/25/2023

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