MEDICARE: NICOLE BURGESS LMFT

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	106H00000X	Marriage & Family Therapist	35001684	IN

General Provider Information

NPI Number	:	1932224870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE BURGESS LMFT

Provider Business Mailing Address
First Line	:	PO BOX 29490
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-0490
Country	:	US
Telephone Number	:	317-840-0490
Fax Number	:

Provider Business Practice Location Address
First Line	:	7002 GRAHAM RD
Second Line	:	SUITE 211
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4057
Country	:	US
Telephone Number	:	317-840-0490
Fax Number	:

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	10/20/2016

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