Healthcare Provider Details

I. General information

NPI: 1265644637
Provider Name (Legal Business Name): ELWOOD JOHNSON BURGESS JR. PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 05/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3824 BARRETT DR SUITE 101
RALEIGH NC
27609-7220
US

IV. Provider business mailing address

3509 HAWORTH DR STE 404
RALEIGH NC
27609-7237
US

V. Phone/Fax

Practice location:
  • Phone: 919-785-9944
  • Fax: 919-785-9992
Mailing address:
  • Phone: 919-785-9944
  • Fax: 919-785-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2249
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2249
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2249
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number2249
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number2249
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: