Healthcare Provider Details

I. General information

NPI: 1932756038
Provider Name (Legal Business Name): MYRON JON BURGER LSAA, LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CERRILLOS RD
SANTA FE NM
87505-3521
US

IV. Provider business mailing address

1501 CERRILLOS RD
SANTA FE NM
87505-3521
US

V. Phone/Fax

Practice location:
  • Phone: 602-565-1656
  • Fax: 505-212-0576
Mailing address:
  • Phone: 602-565-1656
  • Fax: 505-212-0576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0218661
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0151611
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: