=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053503441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETH LAURIE BURCHAM LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2007
-----------------------------------------------------
Last Update Date | 08/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 13TH ST SUITE 305
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80302-5240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-717-2177
-----------------------------------------------------
Fax | 303-444-8180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 13TH ST SUITE 305
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80302-5240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-717-2177
-----------------------------------------------------
Fax | 303-444-8180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2558
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------