Provider Demographics
NPI:1053555771
Name:COHEN, MADELINE BURGEN (LCSW)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:BURGEN
Last Name:COHEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7775 E. WINDRIVER DR.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-7017
Mailing Address - Country:US
Mailing Address - Phone:520-243-9287
Mailing Address - Fax:
Practice Address - Street 1:5215 N, SABINO CANYON RD.
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-6435
Practice Address - Country:US
Practice Address - Phone:520-243-9287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-19191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ744468Medicaid
AZZ131485Medicare PIN