=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528941697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DE-ASIA S BURROUGHS
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2025
-----------------------------------------------------
Last Update Date | 07/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 N MATTHEWS RD
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29560-7027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-394-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 RIPLEY RD
-----------------------------------------------------
City | SCRANTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29591-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-598-7142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------