Provider Demographics
NPI:1104912898
Name:BURTH, GLORIA (LCSW)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:BURTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63-85 WOODHAVEN BLVD
Mailing Address - Street 2:APT 6H
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4850
Mailing Address - Country:US
Mailing Address - Phone:718-478-1554
Mailing Address - Fax:
Practice Address - Street 1:75-01 BROADWAY 3RD FL
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-478-1554
Practice Address - Fax:718-478-3844
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP055498-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY055498-A37OtherHEALTHFIRST
NYP98065Medicare UPIN
NY03823QMedicare ID - Type Unspecified