Provider Demographics
NPI:1265644637
Name:BURGESS, ELWOOD JOHNSON JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELWOOD
Middle Name:JOHNSON
Last Name:BURGESS
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 HAWORTH DR
Mailing Address - Street 2:STE 404
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7237
Mailing Address - Country:US
Mailing Address - Phone:919-785-9944
Mailing Address - Fax:919-785-9992
Practice Address - Street 1:3824 BARRETT DR
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7220
Practice Address - Country:US
Practice Address - Phone:919-785-9944
Practice Address - Fax:919-785-9992
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2018-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2249103G00000X, 103TC0700X, 103TC2200X, 103TF0200X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0310EOtherBCBSNC
NC176TUOtherBC/BS EFF 2/1/2013
NC6000342Medicaid
NC176TUOtherBC/BS EFF 2/1/2013