Provider Demographics
NPI:1396211884
Name:BURROUGHS, CAROLYN (OWNER)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2665
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-2665
Mailing Address - Country:US
Mailing Address - Phone:248-937-0917
Mailing Address - Fax:248-353-2131
Practice Address - Street 1:26962 FRANKLIN RD APT 131
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2437
Practice Address - Country:US
Practice Address - Phone:248-353-2100
Practice Address - Fax:248-353-2131
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703119439164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse