Provider Demographics
NPI:1346788833
Name:BURTON, SHAKINNA LUCILLE
Entity Type:Individual
Prefix:
First Name:SHAKINNA
Middle Name:LUCILLE
Last Name:BURTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAKINNA
Other - Middle Name:LUCILLE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1956 TERRITORIAL RD
Mailing Address - Street 2:APT 6
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-8086
Mailing Address - Country:US
Mailing Address - Phone:269-934-1621
Mailing Address - Fax:
Practice Address - Street 1:1485 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5711
Practice Address - Country:US
Practice Address - Phone:180-033-6034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker