Healthcare Provider Details

I. General information

NPI: 1003228792
Provider Name (Legal Business Name): THOMAS BURDICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISBO CA
93401
US

IV. Provider business mailing address

4001 EL POMAR DR
TEMPLETON CA
93465
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4711
  • Fax:
Mailing address:
  • Phone: 805-903-3640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: