Provider Demographics
NPI:1861615890
Name:BURGESS, REGINALD DAVID (MS, LCPC, LCADC)
Entity type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:DAVID
Last Name:BURGESS
Suffix:
Gender:M
Credentials:MS, LCPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8830 ORCHARD TREE LN STE 127
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21286-2143
Mailing Address - Country:US
Mailing Address - Phone:443-632-3606
Mailing Address - Fax:443-632-3652
Practice Address - Street 1:8830 ORCHARD TREE LN
Practice Address - Street 2:SUITE 127
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-2143
Practice Address - Country:US
Practice Address - Phone:443-632-3606
Practice Address - Fax:443-632-3652
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA407101YA0400X
MDLC2419101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD013444900Medicaid