Healthcare Provider Details

I. General information

NPI: 1528449964
Provider Name (Legal Business Name): LEROY BURGESS PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S SAINT LOUIS BLVD STE 202
SOUTH BEND IN
46617-3044
US

IV. Provider business mailing address

300 S SAINT LOUIS BLVD STE 202
SOUTH BEND IN
46617-3044
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-1405
  • Fax: 574-232-0124
Mailing address:
  • Phone: 574-232-1405
  • Fax: 574-232-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number99066271A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: