Provider Demographics
NPI:1891335220
Name:BURCIAGA, DESEARY MONIQUE
Entity Type:Individual
Prefix:
First Name:DESEARY
Middle Name:MONIQUE
Last Name:BURCIAGA
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 1:11565 LAUREL CANYON BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4650
Mailing Address - Country:US
Mailing Address - Phone:818-361-5030
Mailing Address - Fax:
Practice Address - Street 1:11565 LAUREL CANYON BLVD STE 116
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4650
Practice Address - Country:US
Practice Address - Phone:818-361-5030
Practice Address - Fax:818-365-3475
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA946221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical