Healthcare Provider Details

I. General information

NPI: 1740101096
Provider Name (Legal Business Name): RONNIE BURGESS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 RANDOLPH PL
NEWARK NJ
07108-1208
US

IV. Provider business mailing address

27 MENZEL AVE
MAPLEWOOD NJ
07040-3307
US

V. Phone/Fax

Practice location:
  • Phone: 862-763-1334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC01286500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: