Provider Demographics
NPI:1972935559
Name:BURGESS, MOLLIE-JEAN (MSED, ATC)
Entity type:Individual
Prefix:
First Name:MOLLIE-JEAN
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MSED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 LONGDALE DR
Mailing Address - Street 2:APT 101
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23513-4731
Mailing Address - Country:US
Mailing Address - Phone:401-741-0845
Mailing Address - Fax:
Practice Address - Street 1:800 E CITY HALL AVE
Practice Address - Street 2:SUITE 800
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2723
Practice Address - Country:US
Practice Address - Phone:401-741-0845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260016952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer