Provider Demographics
NPI:1053507103
Name:BURNS, MARK (LPC, MS, PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BURNS
Suffix:
Gender:M
Credentials:LPC, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 N CALHOUN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-1336
Mailing Address - Country:US
Mailing Address - Phone:262-781-8123
Mailing Address - Fax:414-434-3939
Practice Address - Street 1:4040 N CALHOUN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-1336
Practice Address - Country:US
Practice Address - Phone:262-781-8123
Practice Address - Fax:262-437-1300
Is Sole Proprietor?:No
Enumeration Date:2007-09-22
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI326-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional