Provider Demographics
NPI:1780274126
Name:BURGOS, CARMEN JOANNIE
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:JOANNIE
Last Name:BURGOS
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 1:211 OWENSHIRE CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-8475
Mailing Address - Country:US
Mailing Address - Phone:407-962-5382
Mailing Address - Fax:
Practice Address - Street 1:2208 W COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3436
Practice Address - Country:US
Practice Address - Phone:407-201-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty