Provider Demographics
NPI:1356853311
Name:RAINA BURLAK PA
Entity Type:Organization
Organization Name:RAINA BURLAK PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAINA
Authorized Official - Middle Name:RAINBOW
Authorized Official - Last Name:BURLAK
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC NCC
Authorized Official - Phone:239-821-9754
Mailing Address - Street 1:12553 NEW BRITTANY BOULEVARD
Mailing Address - Street 2:SUITE 32
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:239-689-3079
Mailing Address - Fax:239-313-6923
Practice Address - Street 1:12553 NEW BRITTANY BLVD STE 32
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3625
Practice Address - Country:US
Practice Address - Phone:239-689-3079
Practice Address - Fax:239-313-6923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14350101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty