MEDICARE: DR. AUDREY FRANCES BURGESS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	32242	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	87237A	OTHER	TX	BCBS PROVIDER I.D. NUMBER

General Provider Information

NPI Number	:	1356456750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUDREY FRANCES BURGESS PH.D.

Provider Business Mailing Address
First Line	:	608 PEDEN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-1424
Country	:	US
Telephone Number	:	713-377-8657
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 PEDEN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-1424
Country	:	US
Telephone Number	:	713-377-8657
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	05/26/2009

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