Healthcare Provider Details

I. General information

NPI: 1104641844
Provider Name (Legal Business Name): ANGELIQUE BURNSIDE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 24TH AVE NW STE 101
NORMAN OK
73069-6666
US

IV. Provider business mailing address

1002 LINDEN LN
NOBLE OK
73068-8323
US

V. Phone/Fax

Practice location:
  • Phone: 405-364-6432
  • Fax:
Mailing address:
  • Phone: 405-401-9376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPCCANDIDATE12495
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: