Provider Demographics
NPI:1700992062
Name:BURGESS, DOUGLAS DUBOIS (LCSW)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DUBOIS
Last Name:BURGESS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:SUITE A-160
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-269-1500
Practice Address - Fax:805-269-1585
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 135341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71031FMedicaid
SW13534OtherPPIN
CAW1508OtherMEDICARE PTAN GROUP
SW13534OtherPPIN