Provider Demographics
NPI:1427286905
Name:BURGESS, LODEMA
Entity type:Individual
Prefix:
First Name:LODEMA
Middle Name:
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 1:805 DUNN STORE RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261-8271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 DUNN STORE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261-8271
Practice Address - Country:US
Practice Address - Phone:270-526-6265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist