Healthcare Provider Details

I. General information

NPI: 1720846967
Provider Name (Legal Business Name): MARY E BURCHAM LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 03/12/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W 4TH NORTH FT.STREET
SUMMERVILLE SC
29483
US

IV. Provider business mailing address

9366 AYSCOUGH RD
SUMMERVILLE SC
29485-8677
US

V. Phone/Fax

Practice location:
  • Phone: 843-501-1099
  • Fax:
Mailing address:
  • Phone: 843-437-9711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8523
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: