Provider Demographics
NPI:1396354536
Name:BURGOON, DAVE (LPCC)
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:BURGOON
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 ROLLING CT
Mailing Address - Street 2:
Mailing Address - City:EKRON
Mailing Address - State:KY
Mailing Address - Zip Code:40117-8649
Mailing Address - Country:US
Mailing Address - Phone:270-305-1820
Mailing Address - Fax:
Practice Address - Street 1:668 BYPASS RD
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1730
Practice Address - Country:US
Practice Address - Phone:270-305-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY263815101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100694080Medicaid