Healthcare Provider Details

I. General information

NPI: 1912259219
Provider Name (Legal Business Name): BRIAN JAMES BURKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N 1ST ST #2
ANN ARBOR MI
48104-1397
US

IV. Provider business mailing address

367 MEADOWIND CT
PINCKNEY MI
48169-8939
US

V. Phone/Fax

Practice location:
  • Phone: 734-648-0061
  • Fax:
Mailing address:
  • Phone: 734-648-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: