Provider Demographics
NPI:1528449964
Name:BURGESS, LEROY (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:LEROY
Middle Name:
Last Name:BURGESS
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S SAINT LOUIS BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3044
Mailing Address - Country:US
Mailing Address - Phone:574-232-1405
Mailing Address - Fax:574-232-0124
Practice Address - Street 1:300 S SAINT LOUIS BLVD STE 202
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3044
Practice Address - Country:US
Practice Address - Phone:574-232-1405
Practice Address - Fax:574-232-0124
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99066271A103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service