Healthcare Provider Details

I. General information

NPI: 1336157817
Provider Name (Legal Business Name): JONATHAN BURCH M.A., L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 HIGHWAY 95 STE 104
BULLHEAD CITY AZ
86442-7802
US

IV. Provider business mailing address

1014 HITCHCOCK DR SW
AIKEN SC
29803-5399
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-0250
  • Fax: 928-763-0271
Mailing address:
  • Phone: 803-514-2977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-1903
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: