Provider Demographics
NPI:1932224870
Name:BURGESS, NICOLE (LMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LMFT
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 29490
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-0490
Mailing Address - Country:US
Mailing Address - Phone:317-840-0490
Mailing Address - Fax:
Practice Address - Street 1:7002 GRAHAM RD
Practice Address - Street 2:SUITE 211
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4057
Practice Address - Country:US
Practice Address - Phone:317-840-0490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001684106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist