Provider Demographics
NPI:1750681649
Name:BURLYGA, MICHELLE REBECCA (OTRL)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:REBECCA
Last Name:BURLYGA
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 ILIKAI AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-1940
Mailing Address - Country:US
Mailing Address - Phone:626-840-9532
Mailing Address - Fax:
Practice Address - Street 1:2001 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1136
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:408-254-9960
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health