Provider Demographics
NPI:1922148964
Name:BURGOYNE, WILFRED CHARLES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:WILFRED
Middle Name:CHARLES
Last Name:BURGOYNE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-3410
Mailing Address - Country:US
Mailing Address - Phone:718-693-8700
Mailing Address - Fax:718-693-8447
Practice Address - Street 1:163 STRATFORD RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3410
Practice Address - Country:US
Practice Address - Phone:718-693-8700
Practice Address - Fax:718-693-8447
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR139971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3636127Medicare UPIN
NYN87221Medicare ID - Type UnspecifiedMENTAL HEALTH LCSW
NY203734Medicare UPIN
NYMHS581244Medicare UPIN