Provider Demographics
NPI:1134591167
Name:BURGOS, EDNA C (ASW)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:C
Last Name:BURGOS
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1516
Mailing Address - Country:US
Mailing Address - Phone:619-702-4186
Mailing Address - Fax:619-702-5924
Practice Address - Street 1:823 GATEWAY CENTER WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4541
Practice Address - Country:US
Practice Address - Phone:619-515-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW35321101YM0800X
CA855971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health