Provider Demographics
NPI:1013377233
Name:BURGESS, JUSTIN (CSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BURGESS
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5447
Mailing Address - Country:US
Mailing Address - Phone:307-324-7156
Mailing Address - Fax:307-328-1651
Practice Address - Street 1:721 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5447
Practice Address - Country:US
Practice Address - Phone:307-324-7156
Practice Address - Fax:307-328-1651
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCSW-2521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical