MEDICARE: MS. TIERRA MARIA BURKETT LCSWA

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	1041C0700X	Clinical Social Worker	P011633	NC

General Provider Information

NPI Number	:	1497211130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TIERRA MARIA BURKETT LCSWA

Provider Business Mailing Address
First Line	:	3201 SUGAR PINE TRL APT 105
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-6262
Country	:	US
Telephone Number	:	910-554-2983
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 W MILLBROOK RD STE 129
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-4398
Country	:	US
Telephone Number	:	919-877-6101
Fax Number	:

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

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	02/19/2019

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