MEDICARE: MRS. CLARYCE VERNA BURRIS LCSW,CADACIV,NCAC II

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	TO BE GRANDFATHERED	IN
2	1041C0700X	Clinical Social Worker	340001113A	IN

General Provider Information

NPI Number	:	1689996811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CLARYCE VERNA BURRIS LCSW,CADACIV,NCAC II

Provider Business Mailing Address
First Line	:	1950 W 86TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-2076
Country	:	US
Telephone Number	:	317-824-1725
Fax Number	:

Provider Business Practice Location Address
First Line	:	1950 W 86TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-2076
Country	:	US
Telephone Number	:	317-824-1725
Fax Number	:

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

Provider Enumeration Date	:	02/15/2010
Last Update Date	:	02/15/2010

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