Provider Demographics
NPI:1417359167
Name:BURGOON, ERICA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:
Last Name:BURGOON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WESTMONT AVE
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-1716
Mailing Address - Country:US
Mailing Address - Phone:856-816-7098
Mailing Address - Fax:
Practice Address - Street 1:525 S 4TH ST
Practice Address - Street 2:SUITE 417
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1570
Practice Address - Country:US
Practice Address - Phone:267-861-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016552103TC0700X
DEB1-0000957103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical