Basic Information
| Provider Information | |||||||||
| NPI: | 1376264101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | JANELLE-RICHY | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 981 US HIGHWAY 22 FL 2 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEWATER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088072946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018017141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 654 BROADWAY FL 2 | ||||||||
| Address2: | |||||||||
| City: | BAYONNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070026555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013544410 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2022 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA02124300 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.