Provider Demographics
NPI:1457046260
Name:BURGOS, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:BURGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 RIGI AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2234
Mailing Address - Country:US
Mailing Address - Phone:315-243-0755
Mailing Address - Fax:
Practice Address - Street 1:1045 JAMES ST STE 100
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2758
Practice Address - Country:US
Practice Address - Phone:315-472-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118874104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker