Provider Demographics
NPI:1396733663
Name:BURGOYNE, PAMELA M (LCSW)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:BURGOYNE
Suffix:
Gender:F
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:PO BOX 6605
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85261-6605
Mailing Address - Country:US
Mailing Address - Phone:602-256-9599
Mailing Address - Fax:480-585-6109
Practice Address - Street 1:14623 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85045-0456
Practice Address - Country:US
Practice Address - Phone:602-256-9599
Practice Address - Fax:480-585-6109
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSW0540I104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ21305Medicare ID - Type Unspecified
R03031Medicare UPIN