Provider Demographics
NPI:1104985258
Name:BURGESS, VINCE (LMFT)
Entity type:Individual
Prefix:MR
First Name:VINCE
Middle Name:
Last Name:BURGESS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 DOBBINS ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3931
Mailing Address - Country:US
Mailing Address - Phone:707-469-4540
Mailing Address - Fax:707-469-4560
Practice Address - Street 1:233 DOBBINS ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3931
Practice Address - Country:US
Practice Address - Phone:707-469-4540
Practice Address - Fax:707-469-4560
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 41647106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist