Provider Demographics
NPI:1871027573
Name:BURTON, TINA D (MED, MS, CMT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:D
Last Name:BURTON
Suffix:
Gender:F
Credentials:MED, MS, CMT
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:D
Other - Last Name:FRAZIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:33 CHEVY CHASE RD
Mailing Address - Street 2:
Mailing Address - City:ERIAL
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-4328
Mailing Address - Country:US
Mailing Address - Phone:856-366-7064
Mailing Address - Fax:
Practice Address - Street 1:33 CHEVY CHASE RD
Practice Address - Street 2:
Practice Address - City:ERIAL
Practice Address - State:NJ
Practice Address - Zip Code:08081-4328
Practice Address - Country:US
Practice Address - Phone:856-366-7064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAM1143251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0064050Medicaid