Provider Demographics
NPI:1316389638
Name:BURDICK, SHANNON M (LSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:BURDICK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 MANTUA BLVD
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:NJ
Mailing Address - Zip Code:08051-1057
Mailing Address - Country:US
Mailing Address - Phone:856-873-7001
Mailing Address - Fax:
Practice Address - Street 1:901 ROUTE 168
Practice Address - Street 2:SUITE 104
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-3210
Practice Address - Country:US
Practice Address - Phone:856-816-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-28
Last Update Date:2013-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05748800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker