MEDICARE: SOPHIA ANNA BURGESS

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	106S00000X	Behavior Technician	RBT-21-180573	VA

General Provider Information

NPI Number	:	1316691686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA ANNA BURGESS

Provider Business Mailing Address
First Line	:	10815 PEACH TREE DR
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22407-7315
Country	:	US
Telephone Number	:	240-907-8703
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 FALL HILL AVE STE 105
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-3570
Country	:	US
Telephone Number	:	540-899-5790
Fax Number	:

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

Provider Enumeration Date	:	02/07/2022
Last Update Date	:	02/07/2022

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Directions to “ SOPHIA ANNA BURGESS ” Practice Location

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