Provider Demographics
NPI:1083958839
Name:BURRIS, MICHELE M (LADC/MH)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:BURRIS
Suffix:
Gender:F
Credentials:LADC/MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-8103
Mailing Address - Country:US
Mailing Address - Phone:405-623-7163
Mailing Address - Fax:
Practice Address - Street 1:11500 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-8103
Practice Address - Country:US
Practice Address - Phone:405-623-7163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-17
Last Update Date:2012-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health