Healthcare Provider Details

I. General information

NPI: 1538471370
Provider Name (Legal Business Name): IAIN DOUGLAS BURGUET MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N ELM AVE
SAINT LOUIS MO
63119-2418
US

IV. Provider business mailing address

110 N ELM AVE
SAINT LOUIS MO
63119-2418
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-5718
  • Fax: 314-918-1521
Mailing address:
  • Phone: 314-961-5718
  • Fax: 314-918-1521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2010001234
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: