MEDICARE: MRS. ABBY C BOERNER LPC

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	2862	GA

General Provider Information

NPI Number	:	1619200284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ABBY C BOERNER LPC

Provider Business Mailing Address
First Line	:	605 DEPOT DR
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30461-6709
Country	:	US
Telephone Number	:	912-690-0324
Fax Number	:	912-858-4350

Provider Business Practice Location Address
First Line	:	112 N COLLEGE ST
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5309
Country	:	US
Telephone Number	:	912-690-0324
Fax Number	:	912-858-4350

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

Provider Enumeration Date	:	09/14/2009
Last Update Date	:	09/14/2009

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