Provider Demographics
NPI:1265838866
Name:BURGESS, NICHOLE
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:BURGESS
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 1:21299 DUNK FREELAND RD
Mailing Address - Street 2:
Mailing Address - City:PARKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21120-9270
Mailing Address - Country:US
Mailing Address - Phone:443-465-8994
Mailing Address - Fax:
Practice Address - Street 1:1212 E CHURCHVILLE RD STE 301
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3482
Practice Address - Country:US
Practice Address - Phone:443-640-4913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-08
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9510101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional