Provider Demographics
NPI:1538579081
Name:BURTCH, ROBERT DALE (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DALE
Last Name:BURTCH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5072 ALLRED RD
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-9705
Mailing Address - Country:US
Mailing Address - Phone:209-604-5939
Mailing Address - Fax:209-966-2831
Practice Address - Street 1:5072 ALLRED RD
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9705
Practice Address - Country:US
Practice Address - Phone:209-604-5939
Practice Address - Fax:209-966-2831
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS29794251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health