Provider Demographics
NPI:1447266515
Name:BURGESS, BEN (MA, TLLP)
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:BURGESS
Suffix:
Gender:M
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1231
Mailing Address - Country:US
Mailing Address - Phone:616-842-4772
Mailing Address - Fax:616-842-5575
Practice Address - Street 1:321 FULTON ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1231
Practice Address - Country:US
Practice Address - Phone:616-842-4772
Practice Address - Fax:616-842-5575
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013254103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist