MEDICARE: DR. VIRGINIA LEE BURGESS LISW

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	1041C0700X	Clinical Social Worker	I-06004	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	644452	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1457339764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIRGINIA LEE BURGESS LISW

Provider Business Mailing Address
First Line	:	1001 W BROADWAY STE D
Second Line	:	BEHAVIORAL HEALTH DEPT.
City	:	FARMINGTON
State	:	NM
Zip	:	87401-5638
Country	:	US
Telephone Number	:	505-566-0317
Fax Number	:	505-327-7247

Provider Business Practice Location Address
First Line	:	1001 W BROADWAY STE D
Second Line	:	BEHAVIORAL HEALTH DEPT.
City	:	FARMINGTON
State	:	NM
Zip	:	87401-5638
Country	:	US
Telephone Number	:	505-566-0317
Fax Number	:	505-327-7247

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

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. VIRGINIA LEE BURGESS LISW” Practice Location

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