Basic Information
| Provider Information | |||||||||
| NPI: | 1649757972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | YUSHICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1547 PARKWAY | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296464081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642291720 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2043 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | NEWBERRY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291082249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032768000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2018 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 3335 | 01 | SC | MEDICARE | OTHER | 421504 | 05 | SC | MEDICAID |