Healthcare Provider Details

I. General information

NPI: 1174632145
Provider Name (Legal Business Name): BLAINE G. BURKS L.M.S.W.,CAAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E MARKET ST STE 3
LIMA OH
45801-4535
US

IV. Provider business mailing address

19323 ARDMORE ST
DETROIT MI
48235-1704
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-4474
  • Fax: 419-222-7044
Mailing address:
  • Phone: 313-585-2242
  • Fax: 313-397-1547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6801064874
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: