Provider Demographics
NPI:1083281059
Name:BURLESON, VIRGINIA (LCSW)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:BURLESON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 FAIRMOUNT AVE UNIT 1036
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-2483
Mailing Address - Country:US
Mailing Address - Phone:215-870-4458
Mailing Address - Fax:
Practice Address - Street 1:1700 SANSOM ST FL 11
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5245
Practice Address - Country:US
Practice Address - Phone:215-563-7863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW138012104100000X
PACW0243151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker