Provider Demographics
NPI:1780464727
Name:BURGESS, TABATHA DANIELLE
Entity type:Individual
Prefix:
First Name:TABATHA
Middle Name:DANIELLE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2411
Mailing Address - Country:US
Mailing Address - Phone:304-638-8766
Mailing Address - Fax:
Practice Address - Street 1:63 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2411
Practice Address - Country:US
Practice Address - Phone:304-638-8766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor