Provider Demographics
NPI:1083608988
Name:BURBANK, THERESA M (MA LPC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:BURBANK
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WEST PAULINE
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301
Mailing Address - Country:US
Mailing Address - Phone:936-760-1880
Mailing Address - Fax:936-760-9101
Practice Address - Street 1:112 WEST PAULINE
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301
Practice Address - Country:US
Practice Address - Phone:936-760-1880
Practice Address - Fax:936-760-9101
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15294101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1131716-02Medicaid