Healthcare Provider Details

I. General information

NPI: 1518210079
Provider Name (Legal Business Name): ELVIN THOMASEO BURTON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 11/15/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST STE. G145
MEMPHIS TN
38105-4625
US

IV. Provider business mailing address

186 MARKET ST # 310
MEMPHIS TN
38105-3537
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-5565
  • Fax:
Mailing address:
  • Phone: 617-445-1579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3295
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9642
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS019677
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: