Provider Demographics
NPI:1780166892
Name:BURGESS, TONI COLLENE
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:COLLENE
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 1:23600 MARINE VIEW DR S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-7352
Mailing Address - Country:US
Mailing Address - Phone:206-401-4113
Mailing Address - Fax:
Practice Address - Street 1:23600 MARINE VIEW DR S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-7352
Practice Address - Country:US
Practice Address - Phone:206-401-4113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
WA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant