MEDICARE: MS. LAGRACIA BURNETT M.E.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1760750798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAGRACIA BURNETT M.E.

Provider Business Mailing Address
First Line	:	8612 FORREST AVE.
Second Line	:
City	:	PHILA.
State	:	PA
Zip	:	19150
Country	:	US
Telephone Number	:	267-439-6721
Fax Number	:	215-248-1011

Provider Business Practice Location Address
First Line	:	8612 FORREST AVE
Second Line	:
City	:	PHILA.
State	:	PA
Zip	:	19150
Country	:	US
Telephone Number	:	267-439-6721
Fax Number	:	215-248-1011

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2011
Last Update Date	:	02/23/2015

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