Provider Demographics
NPI:1982354684
Name:BURGOS, CARLA SOPHIA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:SOPHIA
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 1:4996 LA SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-2612
Mailing Address - Country:US
Mailing Address - Phone:951-525-3752
Mailing Address - Fax:
Practice Address - Street 1:4996 LA SIERRA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-2612
Practice Address - Country:US
Practice Address - Phone:951-525-3752
Practice Address - Fax:951-358-0762
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist