Provider Demographics
NPI:1740830330
Name:BURTON, SAM OMAR (MSW, LSW)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:OMAR
Last Name:BURTON
Suffix:
Gender:M
Credentials:MSW, LSW
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 483
Mailing Address - Street 2:
Mailing Address - City:COCHRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:16314-0483
Mailing Address - Country:US
Mailing Address - Phone:814-882-2364
Mailing Address - Fax:
Practice Address - Street 1:3910 CAUGHEY ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506
Practice Address - Country:US
Practice Address - Phone:814-541-5296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW136084104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker