Provider Demographics
NPI:1255128625
Name:BURGOS-LAWRENCE, KHAILANI
Entity type:Individual
Prefix:
First Name:KHAILANI
Middle Name:
Last Name:BURGOS-LAWRENCE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 SPRINGSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 SPRINGSIDE AVE
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-1658
Practice Address - Country:US
Practice Address - Phone:860-719-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician