Provider Demographics
NPI:1225561053
Name:BURKHALTER, MAE MOON (ASS)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:MOON
Last Name:BURKHALTER
Suffix:
Gender:F
Credentials:ASS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 NW 11TH ST APT 15
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-3915
Mailing Address - Country:US
Mailing Address - Phone:918-361-6380
Mailing Address - Fax:
Practice Address - Street 1:409 NW 11TH ST APT 15
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-3915
Practice Address - Country:US
Practice Address - Phone:918-631-6380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-08
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)