Provider Demographics
NPI:1346563137
Name:BURGESS, DANNY RAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DANNY
Middle Name:RAY
Last Name:BURGESS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 LAKELAND DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5029
Mailing Address - Country:US
Mailing Address - Phone:601-713-1550
Mailing Address - Fax:
Practice Address - Street 1:1350 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5112
Practice Address - Country:US
Practice Address - Phone:601-981-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS49854103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06359856Medicaid
MS518233YJ5DMedicare PIN