=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861203168
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA RAE BURTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2025
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 SE 192ND AVE STE 203
-----------------------------------------------------
City | CAMAS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98607-7415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-319-3053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14718 SW SHOUE DR
-----------------------------------------------------
City | TIGARD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97224-0915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-803-8229
-----------------------------------------------------
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 | MC61614549
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | R10576
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------