Provider Demographics
NPI:1679151468
Name:BURGE, BREANNA RENAY (BSSW, LSW)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:RENAY
Last Name:BURGE
Suffix:
Gender:F
Credentials:BSSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-1736
Mailing Address - Country:US
Mailing Address - Phone:740-914-5000
Mailing Address - Fax:
Practice Address - Street 1:827 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-1736
Practice Address - Country:US
Practice Address - Phone:740-914-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1904431101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor