Provider Demographics
NPI:1730250069
Name:BURSON, GWEN
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:BURSON
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 1:11344 COLOMA RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-4457
Mailing Address - Country:US
Mailing Address - Phone:916-501-6706
Mailing Address - Fax:916-852-5838
Practice Address - Street 1:11344 COLOMA RD
Practice Address - Street 2:SUITE 250
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-4457
Practice Address - Country:US
Practice Address - Phone:916-501-6706
Practice Address - Fax:916-852-5838
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36715106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist