Provider Demographics
NPI:1790107878
Name:BURGESS, NAOMI (DPT)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NAOMI
Other - Middle Name:
Other - Last Name:EHRLICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:521 E JUANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6022
Mailing Address - Country:US
Mailing Address - Phone:186-348-8885
Mailing Address - Fax:
Practice Address - Street 1:299 W FOOTHILL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-985-2337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist