Healthcare Provider Details

I. General information

NPI: 1558279604
Provider Name (Legal Business Name): LAKEIA RICHELLE NICOLE BURRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 KELLY ST
BRONX NY
10455-1911
US

IV. Provider business mailing address

730 KELLY ST
BRONX NY
10455-1911
US

V. Phone/Fax

Practice location:
  • Phone: 718-542-4127
  • Fax:
Mailing address:
  • Phone: 718-542-4127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number42153
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: