MEDICARE: PAMELA M BURGOYNE LCSW

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	104100000X	Social Worker	SW0540I	AZ

General Provider Information

NPI Number	:	1396733663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA M BURGOYNE LCSW

Provider Business Mailing Address
First Line	:	PO BOX 6605
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85261-6605
Country	:	US
Telephone Number	:	602-256-9599
Fax Number	:	480-585-6109

Provider Business Practice Location Address
First Line	:	14623 S 4TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85045-0456
Country	:	US
Telephone Number	:	602-256-9599
Fax Number	:	480-585-6109

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	08/06/2012

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