Provider Demographics
NPI:1356589261
Name:BURRELL, WILLIE EDWARD JR
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:EDWARD
Last Name:BURRELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48090-1450
Mailing Address - Country:US
Mailing Address - Phone:313-485-7826
Mailing Address - Fax:
Practice Address - Street 1:13627 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-3433
Practice Address - Country:US
Practice Address - Phone:313-521-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI821198251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management