Provider Demographics
NPI:1528229150
Name:BURGOS, NANCY LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:LYNN
Last Name:BURGOS
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 1:9129 120TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-3215
Mailing Address - Country:US
Mailing Address - Phone:347-683-6628
Mailing Address - Fax:
Practice Address - Street 1:9129 120TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-3215
Practice Address - Country:US
Practice Address - Phone:347-683-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072563104100000X
NY0765401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00072563Medicaid
NY00076540Medicaid