Provider Demographics
NPI:1265145551
Name:BURGESS, SERENA MARY (MS,QMHP, QASP-S, RBT)
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:MARY
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MS,QMHP, QASP-S, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 CAPRI DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-2211
Mailing Address - Country:US
Mailing Address - Phone:707-208-6435
Mailing Address - Fax:
Practice Address - Street 1:8405 RICHMOND HWY STE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-2425
Practice Address - Country:US
Practice Address - Phone:703-595-5664
Practice Address - Fax:571-503-9992
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-20-146508106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician