Healthcare Provider Details

I. General information

NPI: 1700712825
Provider Name (Legal Business Name): ELIZABETH ROSE BURNHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 3RD ST
SHALIMAR FL
32579-1377
US

IV. Provider business mailing address

947 DON DR UNIT E
FORT WALTON BEACH FL
32547-1852
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-4988
  • Fax:
Mailing address:
  • Phone: 850-345-2163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: