Provider Demographics
NPI:1174632145
Name:BURKS, BLAINE G (LMSW,CAAC)
Entity Type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:G
Last Name:BURKS
Suffix:
Gender:M
Credentials:LMSW,CAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19323 ARDMORE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1704
Mailing Address - Country:US
Mailing Address - Phone:313-585-2242
Mailing Address - Fax:313-397-1547
Practice Address - Street 1:311 E MARKET ST STE 3
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4535
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:419-222-7044
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801064874101YA0400X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)