Healthcare Provider Details

I. General information

NPI: 1972879237
Provider Name (Legal Business Name): BURTON DAVID GOTTLIEB MA LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28000 DEQUINDRE RD
WARREN MI
48092-2468
US

IV. Provider business mailing address

1626 MAPLEWOOD ST
SYLVAN LAKE MI
48320-1737
US

V. Phone/Fax

Practice location:
  • Phone: 586-753-1028
  • Fax:
Mailing address:
  • Phone: 258-941-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801060468
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: