MEDICARE: JONATHAN BURCH M.A., L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC-1903	AZ

General Provider Information

NPI Number	:	1336157817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN BURCH M.A., L.P.C.

Provider Business Mailing Address
First Line	:	1014 HITCHCOCK DR SW
Second Line	:
City	:	AIKEN
State	:	SC
Zip	:	29803-5399
Country	:	US
Telephone Number	:	803-514-2977
Fax Number	:

Provider Business Practice Location Address
First Line	:	3003 HIGHWAY 95 STE 104
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7802
Country	:	US
Telephone Number	:	928-763-0250
Fax Number	:	928-763-0271

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	01/08/2010

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