Provider Demographics
NPI:1326505447
Name:BURROUGHS, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BURROUGHS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 S HARRISON ST STE A
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1748
Mailing Address - Country:US
Mailing Address - Phone:973-324-7891
Mailing Address - Fax:
Practice Address - Street 1:86 S HARRISON ST STE A
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1748
Practice Address - Country:US
Practice Address - Phone:973-324-7891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6466403618210Medicaid