Provider Demographics
NPI:1255501359
Name:CAROL R BURKS PHD LLC
Entity Type:Organization
Organization Name:CAROL R BURKS PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:575-524-8404
Mailing Address - Street 1:PO BOX 16254
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-6254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 E IDAHO AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3257
Practice Address - Country:US
Practice Address - Phone:575-524-8404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM651103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty