Provider Demographics
NPI:1053490078
Name:BURGOS, KATRINA M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:M
Last Name:BURGOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KATRINA
Other - Middle Name:MICHELLE
Other - Last Name:COLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:70-50 AUSTIN ST.
Mailing Address - Street 2:LOWER LEVEL SUITE 110A
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:917-509-3379
Mailing Address - Fax:347-960-7779
Practice Address - Street 1:70-50 AUSTIN ST.
Practice Address - Street 2:LOWER LEVEL SUITE 110A
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:917-509-3379
Practice Address - Fax:347-960-7779
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1721061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1120471151OtherTAX ID #