Provider Demographics
NPI:1649573395
Name:BURGAN, DAISY NICHOLSON (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:DAISY
Middle Name:NICHOLSON
Last Name:BURGAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9934
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64134-0934
Mailing Address - Country:US
Mailing Address - Phone:828-817-3931
Mailing Address - Fax:
Practice Address - Street 1:6700 ANTIOCH RD
Practice Address - Street 2:SUITE 430
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204
Practice Address - Country:US
Practice Address - Phone:828-817-3931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010041102224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2010041102OtherSTATE OF MISSOUR BOARD OF OCCUPATIONAL THERAPY