Healthcare Provider Details

I. General information

NPI: 1487972089
Provider Name (Legal Business Name): LONNIE J BURNS JR. LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 05/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 FRISCO AVE
CLINTON OK
73601-3320
US

IV. Provider business mailing address

703 FRISCO AVE
CLINTON OK
73601-3320
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-9100
  • Fax: 580-323-9101
Mailing address:
  • Phone: 580-323-9100
  • Fax: 580-323-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: