Healthcare Provider Details

I. General information

NPI: 1578348926
Provider Name (Legal Business Name): MR. DIEAGO ELLIS BURRESS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5784 FISHER DR APT B
HUBER HEIGHTS OH
45424-5576
US

IV. Provider business mailing address

5784 FISHER DR APT B
HUBER HEIGHTS OH
45424-5576
US

V. Phone/Fax

Practice location:
  • Phone: 937-312-5494
  • Fax:
Mailing address:
  • Phone: 937-312-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: