Healthcare Provider Details

I. General information

NPI: 1154401446
Provider Name (Legal Business Name): RONALD BURKS PMH 823
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 PHYSICIANS DR
TALLAHASSEE FL
32308-4619
US

IV. Provider business mailing address

8894 WAUKEENAH HWY
MONTICELLO FL
32344-7075
US

V. Phone/Fax

Practice location:
  • Phone: 850-431-5144
  • Fax: 850-431-6105
Mailing address:
  • Phone: 850-997-2445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9433
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMH9433
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: