MEDICARE: DEWAYNE BURTS CDAC-I

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	1407	GA

General Provider Information

NPI Number	:	1437882784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEWAYNE BURTS CDAC-I

Provider Business Mailing Address
First Line	:	7937 LAKE STONE CIR
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30134-4086
Country	:	US
Telephone Number	:	845-866-3447
Fax Number	:

Provider Business Practice Location Address
First Line	:	4191 PLEASANT HILL RD STE 100
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-1411
Country	:	US
Telephone Number	:	470-704-5010
Fax Number	:	470-704-5111

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

Provider Enumeration Date	:	07/05/2022
Last Update Date	:	07/05/2022

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