Provider Demographics
NPI:1326209644
Name:BURGESS, LYA J (MSW/LICSW)
Entity Type:Individual
Prefix:
First Name:LYA
Middle Name:J
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MSW/LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NORTH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-1784
Mailing Address - Country:US
Mailing Address - Phone:304-771-8837
Mailing Address - Fax:
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1784
Practice Address - Country:US
Practice Address - Phone:304-771-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVSW19813Medicare PIN