Provider Demographics
NPI:1336665199
Name:BURGOS, AMY MARIE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:BURGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 ORANGE AVE SPC 42
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-4049
Mailing Address - Country:US
Mailing Address - Phone:567-825-3187
Mailing Address - Fax:
Practice Address - Street 1:1465 30TH ST STE K
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3497
Practice Address - Country:US
Practice Address - Phone:619-428-1000
Practice Address - Fax:619-428-1091
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator