Provider Demographics
NPI:1356624753
Name:BURGESS, PARKE GILLETTE JR (LMHCA)
Entity type:Individual
Prefix:MR
First Name:PARKE
Middle Name:GILLETTE
Last Name:BURGESS
Suffix:JR
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 N CHEYENNE ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-4822
Mailing Address - Country:US
Mailing Address - Phone:253-304-1411
Mailing Address - Fax:
Practice Address - Street 1:3503 N CHEYENNE ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-4822
Practice Address - Country:US
Practice Address - Phone:253-304-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60316533101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144986886OtherNPPES