MEDICARE: TAHIRA BURRELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1992530687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAHIRA BURRELL

Provider Business Mailing Address
First Line	:	1437 CARRICK CT
Second Line	:
City	:	MIDDLETOWN
State	:	DE
Zip	:	19709-9970
Country	:	US
Telephone Number	:	215-901-3203
Fax Number	:

Provider Business Practice Location Address
First Line	:	1412 N BOUVIER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19121-4215
Country	:	US
Telephone Number	:	215-901-3203
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2024
Last Update Date	:	09/03/2024

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Directions to “ TAHIRA BURRELL ” Practice Location

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