Provider Demographics
NPI:1629589726
Name:REIS BURGIN, EZEKIAH (LICSW)
Entity Type:Individual
Prefix:
First Name:EZEKIAH
Middle Name:
Last Name:REIS BURGIN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:EZEKIEL
Other - Middle Name:
Other - Last Name:REIS BURGIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:11 ROBERT TONER BLVD
Mailing Address - Street 2:STE 5 # 128
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02763-1156
Mailing Address - Country:US
Mailing Address - Phone:413-569-8124
Mailing Address - Fax:
Practice Address - Street 1:99 ROBERTS ST APT 3
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-9700
Practice Address - Country:US
Practice Address - Phone:413-569-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1248251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical