Provider Demographics
NPI:1063990802
Name:BURKHOLDER, LISA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BURKHOLDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 E LAUREL RD STE 1800-A
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1354
Mailing Address - Country:US
Mailing Address - Phone:856-566-6843
Mailing Address - Fax:856-566-2775
Practice Address - Street 1:42 E LAUREL RD STE 1800-A
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-6843
Practice Address - Fax:856-566-2775
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0193271041C0700X
NJ44SC059058001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0811025Medicaid