Healthcare Provider Details

I. General information

NPI: 1629746680
Provider Name (Legal Business Name): HEATHER BURLESON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15023 21 MILE RD
SHELBY TWP MI
48315-5024
US

IV. Provider business mailing address

15023 21 MILE RD
SHELBY TWP MI
48315-5024
US

V. Phone/Fax

Practice location:
  • Phone: 586-286-9644
  • Fax: 586-286-9644
Mailing address:
  • Phone: 517-212-7406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401003093
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: