Healthcare Provider Details

I. General information

NPI: 1992961692
Provider Name (Legal Business Name): AMY EVANA BURGIN LPE-I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 E OAK ST STE 1
CONWAY AR
72032-4644
US

IV. Provider business mailing address

2215 E OAK ST STE 1
CONWAY AR
72032-4644
US

V. Phone/Fax

Practice location:
  • Phone: 501-336-0511
  • Fax: 501-336-4037
Mailing address:
  • Phone: 501-336-0511
  • Fax: 501-336-4037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number09-18EI
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: