Healthcare Provider Details

I. General information

NPI: 1558504894
Provider Name (Legal Business Name): MICHELLE LYNN BURGESS CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE JOHNSON

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 S 3RD ST
IRONTON OH
45638-1853
US

IV. Provider business mailing address

4304 OLD SCIOTO TRL
PORTSMOUTH OH
45662-6672
US

V. Phone/Fax

Practice location:
  • Phone: 740-351-9298
  • Fax:
Mailing address:
  • Phone: 740-351-9298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.194538
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: