Provider Demographics
NPI:1326709718
Name:BURGESS, WILDINE
Entity type:Individual
Prefix:
First Name:WILDINE
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33568
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3568
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:1012 24TH AVE NW STE 100
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6493
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:619-374-7134
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2025-12-12
Deactivation Date:2024-12-05
Deactivation Code:
Reactivation Date:2025-05-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No172A00000XOther Service ProvidersDriver
No251B00000XAgenciesCase Management
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No385H00000XRespite Care FacilityRespite Care