Provider Demographics
NPI:1770926024
Name:BURGOYNE, MARISSA DIANE (PSYD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:DIANE
Last Name:BURGOYNE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17401 MARTHA ST
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1324
Mailing Address - Country:US
Mailing Address - Phone:310-487-5988
Mailing Address - Fax:
Practice Address - Street 1:17401 MARTHA ST
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1324
Practice Address - Country:US
Practice Address - Phone:310-487-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25601103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical