Provider Demographics
NPI:1689496788
Name:BURGESS, MALEA TIAUN
Entity type:Individual
Prefix:
First Name:MALEA
Middle Name:TIAUN
Last Name:BURGESS
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 1:65 GLEN RD
Mailing Address - Street 2:PMB 309
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529
Mailing Address - Country:US
Mailing Address - Phone:919-636-9966
Mailing Address - Fax:919-636-9966
Practice Address - Street 1:65 GLEN RD
Practice Address - Street 2:PMB 309
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529
Practice Address - Country:US
Practice Address - Phone:919-636-9966
Practice Address - Fax:919-636-9966
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician