Provider Demographics
NPI:1467916064
Name:BURTON, CORLISS REGINA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CORLISS
Middle Name:REGINA
Last Name:BURTON
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 1:3978 BOWEN ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3145
Mailing Address - Country:US
Mailing Address - Phone:314-398-8062
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:314-289-6496
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical