Provider Demographics
NPI:1295395994
Name:BURGIN, PHYLLIS A (LCSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:BURGIN
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 1:24 ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-6328
Mailing Address - Country:US
Mailing Address - Phone:571-251-7477
Mailing Address - Fax:
Practice Address - Street 1:24 ORCHARD LN
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-6328
Practice Address - Country:US
Practice Address - Phone:571-251-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-16
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040100751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty