=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356853311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAINA BURLAK PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2017
-----------------------------------------------------
Last Update Date | 10/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12553 NEW BRITTANY BLVD STE 32
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-689-3079
-----------------------------------------------------
Fax | 239-313-6923
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12553 NEW BRITTANY BOULEVARD SUITE 32
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-689-3079
-----------------------------------------------------
Fax | 239-313-6923
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RAINA RAINBOW BURLAK
-----------------------------------------------------
Credential | LMHC NCC
-----------------------------------------------------
Telephone | 239-821-9754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH14350
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------