Provider Demographics
NPI:1487986147
Name:BURCH, THERESA ANN (LPC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:BURCH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:707 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2219
Mailing Address - Country:US
Mailing Address - Phone:318-869-1632
Mailing Address - Fax:318-869-1633
Practice Address - Street 1:707 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2219
Practice Address - Country:US
Practice Address - Phone:318-869-1632
Practice Address - Fax:318-869-1633
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4085101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional