Healthcare Provider Details

I. General information

NPI: 1487338653
Provider Name (Legal Business Name): LAVONIA M BURGESS BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 LONG HILL RD
STIRLING NJ
07980-1010
US

IV. Provider business mailing address

555 1ST ST APT 250
HARRISON NJ
07029-3185
US

V. Phone/Fax

Practice location:
  • Phone: 908-504-2700
  • Fax:
Mailing address:
  • Phone: 336-406-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: