Provider Demographics
NPI:1497296602
Name:BURGHER-MARTIN, NICOLENE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLENE
Middle Name:
Last Name:BURGHER-MARTIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7107 SUTTON PL FL 2
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4135
Mailing Address - Country:US
Mailing Address - Phone:646-251-0078
Mailing Address - Fax:
Practice Address - Street 1:8802 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1609
Practice Address - Country:US
Practice Address - Phone:718-634-3462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096395-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker