Healthcare Provider Details

I. General information

NPI: 1851354732
Provider Name (Legal Business Name): BURNHAM WOODS CHAMPA & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 MICHIGAN AVE J 2
COCOA FL
32922-5758
US

IV. Provider business mailing address

1970 MICHIGAN AVE J 2
COCOA FL
32922-5758
US

V. Phone/Fax

Practice location:
  • Phone: 321-639-4483
  • Fax: 321-690-0848
Mailing address:
  • Phone: 321-639-4483
  • Fax: 321-690-0848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMH 5004
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 6888
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0004573
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 615
License Number StateFL

VIII. Authorized Official

Name: GARY FRANCIS BURNHAM
Title or Position: OWNER
Credential: LCSW
Phone: 321-639-4483