Provider Demographics
NPI:1073861217
Name:BURGESS, BRIAN THOMAS (LCPC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:BURGESS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3166 N LINCOLN AVE
Mailing Address - Street 2:SUITE 325
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1226
Mailing Address - Country:US
Mailing Address - Phone:773-405-3541
Mailing Address - Fax:
Practice Address - Street 1:3166 N LINCOLN AVE
Practice Address - Street 2:SUITE 325
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3133
Practice Address - Country:US
Practice Address - Phone:773-405-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008239101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health