Healthcare Provider Details

I. General information

NPI: 1427302264
Provider Name (Legal Business Name): PENELOPE MARCIA BURTON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

305 KENWOOD CIR
GADSDEN AL
35904-3608
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-2395
  • Fax: 678-990-3997
Mailing address:
  • Phone: 256-390-6944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006843
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2987
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: