Healthcare Provider Details

I. General information

NPI: 1518880996
Provider Name (Legal Business Name): BLAKE STUART BURDACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 10TH ST
RADFORD VA
24141-3007
US

IV. Provider business mailing address

309 10TH ST
RADFORD VA
24141-3007
US

V. Phone/Fax

Practice location:
  • Phone: 540-818-9989
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0709027011
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704018988
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: