Provider Demographics
NPI:1487220471
Name:BURGESS, EMMA ROSE
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:ROSE
Last Name:BURGESS
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 1:16511 SE 39TH PL
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-5860
Mailing Address - Country:US
Mailing Address - Phone:206-708-4991
Mailing Address - Fax:
Practice Address - Street 1:5031 UNIVERSITY WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4341
Practice Address - Country:US
Practice Address - Phone:206-427-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-45492103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst