MEDICARE: KHRYSTIAN M BURGMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	103K00000X	Behavior Analyst
3	104100000X	Social Worker

General Provider Information

NPI Number	:	1265795686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHRYSTIAN M BURGMAN

Provider Business Mailing Address
First Line	:	2944 GALENA PEAK LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89156-3727
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2944 GALENA PEAK LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89156-3727
Country	:	US
Telephone Number	:	702-556-2158
Fax Number	:

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

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	06/20/2012

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