Healthcare Provider Details

I. General information

NPI: 1194739334
Provider Name (Legal Business Name): MICHAEL KEITH BURNSIDE LPC, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W 7TH ST STE 102
OKMULGEE OK
74447-5007
US

IV. Provider business mailing address

720 S 5TH ST
MORRIS OK
74445-2224
US

V. Phone/Fax

Practice location:
  • Phone: 918-758-1910
  • Fax: 918-756-1270
Mailing address:
  • Phone: 918-733-4603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number553
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2650
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: