Provider Demographics
NPI:1235433384
Name:BURDEN, EVANGELINE V (LMSW)
Entity Type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:V
Last Name:BURDEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21815 BEECH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-5909
Mailing Address - Country:US
Mailing Address - Phone:248-356-2563
Mailing Address - Fax:
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:SUITE 3265
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-836-7563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010055561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801005556OtherMICHIGAN LICENSING BUREAU