Healthcare Provider Details

I. General information

NPI: 1215462726
Provider Name (Legal Business Name): MARSHAREE' BURGESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2017
Last Update Date: 04/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 TROUP ST CATHOLIC FAMILY CENTER
ROCHESTER NY
14608-2053
US

IV. Provider business mailing address

55 TROUP ST CATHOLIC FAMILY CENTER
ROCHESTER NY
14608-2053
US

V. Phone/Fax

Practice location:
  • Phone: 585-336-9034
  • Fax: 585-423-2201
Mailing address:
  • Phone: 585-336-9034
  • Fax: 585-423-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number324889-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number324889-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: