MEDICARE: ISADORA BURNHAM LMFT

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	106H00000X	Marriage & Family Therapist	MFT001771	GA

General Provider Information

NPI Number	:	1881210102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISADORA BURNHAM LMFT

Provider Business Mailing Address
First Line	:	1007 MARY ST
Second Line	:
City	:	WAYCROSS
State	:	GA
Zip	:	31503-3823
Country	:	US
Telephone Number	:	912-449-7111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 SHIRLEY AVE
Second Line	:
City	:	DOUGLAS
State	:	GA
Zip	:	31533-2123
Country	:	US
Telephone Number	:	912-449-7111
Fax Number	:

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

Provider Enumeration Date	:	06/23/2020
Last Update Date	:	06/23/2020

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