Healthcare Provider Details

I. General information

NPI: 1609049899
Provider Name (Legal Business Name): MR. BRUCE D BURLESON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W BRASHER RD TRLR 1
ROSWELL NM
88203-5327
US

IV. Provider business mailing address

333 W BRASHER RD TRLR 1
ROSWELL NM
88203-5327
US

V. Phone/Fax

Practice location:
  • Phone: 508-296-0175
  • Fax: 508-578-5078
Mailing address:
  • Phone: 508-296-0175
  • Fax: 508-578-5078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: