Provider Demographics
NPI:1598783433
Name:BURGESS, CHARLENE MC
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:MC
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 1:3-3367 KUHIO HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-1061
Mailing Address - Country:US
Mailing Address - Phone:808-246-0497
Mailing Address - Fax:808-246-9349
Practice Address - Street 1:3-3367 KUHIO HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1061
Practice Address - Country:US
Practice Address - Phone:808-246-0497
Practice Address - Fax:808-246-9349
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILSW-1079104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker