MEDICARE: MRS. MATTIE J BURNS

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1407012719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MATTIE J BURNS

Provider Business Mailing Address
First Line	:	106 BRUCE RD
Second Line	:
City	:	HOLLY SPRINGS
State	:	MS
Zip	:	38635-6204
Country	:	US
Telephone Number	:	662-224-6763
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 INDUSTRIAL RD
Second Line	:
City	:	ASHLAND
State	:	MS
Zip	:	38603-6761
Country	:	US
Telephone Number	:	662-224-0078
Fax Number	:

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

Provider Enumeration Date	:	08/06/2008
Last Update Date	:	08/06/2008

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