Provider Demographics
NPI:1972987899
Name:BURCH, MATT JAMES
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:JAMES
Last Name:BURCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4073 HIGHWAY 53
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-2305
Mailing Address - Country:US
Mailing Address - Phone:770-882-5884
Mailing Address - Fax:706-658-0116
Practice Address - Street 1:4073 HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-2305
Practice Address - Country:US
Practice Address - Phone:770-882-5884
Practice Address - Fax:706-658-0116
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005247101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003154238AMedicaid