Provider Demographics
NPI:1538349964
Name:BURGESS, MARTIN FRANCIS (LCPC)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:FRANCIS
Last Name:BURGESS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-2447
Mailing Address - Country:US
Mailing Address - Phone:207-283-8574
Mailing Address - Fax:
Practice Address - Street 1:26 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-2447
Practice Address - Country:US
Practice Address - Phone:207-283-8574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2009-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1528101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
040782OtherANTHAM
11540310OtherCAQH
80089575OtherCCR TPIN