Provider Demographics
NPI:1700375383
Name:BURGESS, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2970 E LAKE LANSING RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-7415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2750 CARPENTER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1170
Practice Address - Country:US
Practice Address - Phone:517-230-5695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018398101YP2500X
MI6301016456103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist