Provider Demographics
NPI:1952526402
Name:BURGE, DORLI (PH D)
Entity Type:Individual
Prefix:MS
First Name:DORLI
Middle Name:
Last Name:BURGE
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 MANDEVILLE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-1019
Mailing Address - Country:US
Mailing Address - Phone:310-472-8564
Mailing Address - Fax:
Practice Address - Street 1:1314 WESTWOOD BLVD STE 206
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4928
Practice Address - Country:US
Practice Address - Phone:310-446-4786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12817103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical