Provider Demographics
NPI:1437633088
Name:BURRIS, DAVID ALLEN SR
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:BURRIS
Suffix:SR
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 1:84 SOUTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-4230
Mailing Address - Country:US
Mailing Address - Phone:706-506-7792
Mailing Address - Fax:706-944-4191
Practice Address - Street 1:1875 FANT DR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3307
Practice Address - Country:US
Practice Address - Phone:706-861-3387
Practice Address - Fax:706-639-2054
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1779101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00604513-GAMedicaid