Provider Demographics
NPI:1528396819
Name:BURGESS, BLAIR (CASAC)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:BURGESS
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2857 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-3604
Mailing Address - Country:US
Mailing Address - Phone:718-265-4200
Mailing Address - Fax:718-265-8536
Practice Address - Street 1:2857 W 8TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-3604
Practice Address - Country:US
Practice Address - Phone:718-265-4200
Practice Address - Fax:718-265-8536
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10558101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10558OtherCASAC