Provider Demographics
NPI:1619413606
Name:BURGOS, ELIZABETH (LICSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BURGOS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2226
Mailing Address - Country:US
Mailing Address - Phone:651-602-7552
Mailing Address - Fax:651-602-7580
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107
Practice Address - Country:US
Practice Address - Phone:651-602-7552
Practice Address - Fax:651-602-7580
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN185981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical