Basic Information
| Provider Information | |||||||||
| NPI: | 1700549607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGO | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | THERAPIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURGO | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | COT/L | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 198 SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | NEW BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027404138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085581987 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 68 DEAN ST | ||||||||
| Address2: | |||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027802713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003852527 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2021 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.