Provider Demographics
NPI:1578387106
Name:GEORGIOU, WELLINGTON BURNHAM (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:WELLINGTON
Middle Name:BURNHAM
Last Name:GEORGIOU
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:WELLINGTON
Other - Middle Name:JUDSON
Other - Last Name:HUMES
Other - Suffix:III
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 PINE FLAT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-9610
Mailing Address - Country:US
Mailing Address - Phone:305-934-7605
Mailing Address - Fax:
Practice Address - Street 1:1700 PINE FLAT RD
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-9610
Practice Address - Country:US
Practice Address - Phone:305-934-7605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029934363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health