Provider Demographics
NPI:1972878650
Name:BURCH, RALEIGH L JR
Entity type:Individual
Prefix:MR
First Name:RALEIGH
Middle Name:L
Last Name:BURCH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RALEIGH
Other - Middle Name:
Other - Last Name:BURCH
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LCADC
Mailing Address - Street 1:5419 DEALE CHURCHTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHURCHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20733-2404
Mailing Address - Country:US
Mailing Address - Phone:443-607-6207
Mailing Address - Fax:443-607-6208
Practice Address - Street 1:5419 DEALE CHURCHTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CHURCHTON
Practice Address - State:MD
Practice Address - Zip Code:20733-2404
Practice Address - Country:US
Practice Address - Phone:443-607-6207
Practice Address - Fax:443-607-6208
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA034101Y00000X, 101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415894600Medicaid