Healthcare Provider Details

I. General information

NPI: 1255501359
Provider Name (Legal Business Name): CAROL R BURKS PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E IDAHO AVE SUITE 10
LAS CRUCES NM
88005-3257
US

IV. Provider business mailing address

PO BOX 16254
LAS CRUCES NM
88004-6254
US

V. Phone/Fax

Practice location:
  • Phone: 575-524-8404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number651
License Number StateNM

VIII. Authorized Official

Name: DR. CAROL R BURKS
Title or Position: PHD/PRESIDENT
Credential: PHD
Phone: 575-524-8404