Provider Demographics
NPI:1952998619
Name:BURROUGHS CLAYTON, TIA
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:BURROUGHS CLAYTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 N MOUNT VERNON CIR
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-8207
Mailing Address - Country:US
Mailing Address - Phone:267-971-4837
Mailing Address - Fax:
Practice Address - Street 1:758 2ND STREET PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3972
Practice Address - Country:US
Practice Address - Phone:267-766-0620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137788104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker