Healthcare Provider Details

I. General information

NPI: 1104730852
Provider Name (Legal Business Name): AJANI BURGESS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19140 112TH RD
SAINT ALBANS NY
11412-2412
US

IV. Provider business mailing address

400 W 61ST ST APT 1215
NEW YORK NY
10023-0223
US

V. Phone/Fax

Practice location:
  • Phone: 347-388-6913
  • Fax:
Mailing address:
  • Phone: 347-388-6913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: