Provider Demographics
NPI:1336832609
Name:BURLEY, TYRESE LEWIS
Entity Type:Individual
Prefix:
First Name:TYRESE
Middle Name:LEWIS
Last Name:BURLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TYRESE
Other - Middle Name:LEWIS
Other - Last Name:BURLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5039 VILLA LINDE PKWY STE 30
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3450
Mailing Address - Country:US
Mailing Address - Phone:989-401-2244
Mailing Address - Fax:
Practice Address - Street 1:195 HURON BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1421
Practice Address - Country:US
Practice Address - Phone:989-404-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician