Provider Demographics
NPI:1811231145
Name:BURRAGE, HEATHER (MA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BURRAGE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 HUGHES WAY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810-1876
Mailing Address - Country:US
Mailing Address - Phone:310-221-6336
Mailing Address - Fax:
Practice Address - Street 1:1501 HUGHES WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-1876
Practice Address - Country:US
Practice Address - Phone:310-221-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC88522106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist