MEDICARE: CYVIL B. BURKS, SR., LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	1327	OK

General Provider Information

NPI Number	:	1285905083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CYVIL B. BURKS, SR., LPC

Provider Business Mailing Address
First Line	:	PO BOX 12883
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73157-2883
Country	:	US
Telephone Number	:	405-858-0600
Fax Number	:	405-858-0602

Provider Business Practice Location Address
First Line	:	2212 NW 50TH ST
Second Line	:	SUITE 172C
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8086
Country	:	US
Telephone Number	:	405-808-5229
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CYVIL B BURKS SR.
Credential	:	LPC
Telephone Number	:	405-808-5229

Provider Enumeration Date	:	01/25/2012
Last Update Date	:	01/25/2012

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