MEDICARE: JANELLE RUTH BURNETTE LCASA

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	28030	NC

General Provider Information

NPI Number	:	1922735588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANELLE RUTH BURNETTE LCASA

Provider Business Mailing Address
First Line	:	3209 GRESHAM LAKE RD STE 113
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27615-4131
Country	:	US
Telephone Number	:	919-977-5993
Fax Number	:

Provider Business Practice Location Address
First Line	:	3209 GRESHAM LAKE RD STE 113
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27615-4131
Country	:	US
Telephone Number	:	919-977-5993
Fax Number	:

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

Provider Enumeration Date	:	08/04/2022
Last Update Date	:	08/04/2022

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