=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104641844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELIQUE BURNSIDE LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3261 24TH AVE NW STE 101
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73069-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-364-6432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1002 LINDEN LN
-----------------------------------------------------
City | NOBLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73068-8323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-401-9376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LPCCANDIDATE12495
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------