Provider Demographics
NPI:1912539800
Name:BURGOS, LISBETH
Entity Type:Individual
Prefix:
First Name:LISBETH
Middle Name:
Last Name:BURGOS
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 1:22421 JOLIET AVE
Mailing Address - Street 2:
Mailing Address - City:HAWAIIAN GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90716-1433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22421 JOLIET AVE
Practice Address - Street 2:
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-1433
Practice Address - Country:US
Practice Address - Phone:562-367-9441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician