=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184425613
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAISHA ANDRELL BURNETT CACII
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2025
-----------------------------------------------------
Last Update Date | 03/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1837 HIGHWAY 138 SW
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30296-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-658-1117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 326 BETTY DR
-----------------------------------------------------
City | TENNILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31089-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-357-1406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 20001272
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------