Basic Information
Provider Information | |||||||||
NPI: | 1265597181 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURSON | ||||||||
FirstName: | KIM | ||||||||
MiddleName: | FELITA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16410 ELLIPSE TER | ||||||||
Address2: |   | ||||||||
City: | BOWIE | ||||||||
State: | MD | ||||||||
PostalCode: | 207163262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018096009 | ||||||||
FaxNumber: | 3018092178 | ||||||||
Practice Location | |||||||||
Address1: | 720 N SAINT ASAPH ST | ||||||||
Address2: |   | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 223141912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038384455 | ||||||||
FaxNumber: | 7038385070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701002577 | VA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LC0137 | MD | N |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 0105 | 01 | VA | CAREFIRST BCBS | OTHER | 299085 | 01 | VA | AMERIGROUP VIRGINIA, INC. | OTHER | 188620 | 01 | VA | ANTHEM | OTHER | 5460011003002 | 01 | VA | TRICARE | OTHER |