Healthcare Provider Details

I. General information

NPI: 1316566938
Provider Name (Legal Business Name): PORTIA BURSTION B.S, QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 FM 2920 RD
SPRING TX
77388-3428
US

IV. Provider business mailing address

3505 W SAM HOUSTON PKWY S APT 6405
HOUSTON TX
77042-2155
US

V. Phone/Fax

Practice location:
  • Phone: 281-210-1500
  • Fax:
Mailing address:
  • Phone: 713-539-7127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: