Provider Demographics
NPI:1396831327
Name:BURKHALTER, JOHNNY KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:KENNETH
Last Name:BURKHALTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 LOOP 306
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904
Mailing Address - Country:US
Mailing Address - Phone:325-944-4722
Mailing Address - Fax:325-223-1150
Practice Address - Street 1:3115 LOOP 306
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904
Practice Address - Country:US
Practice Address - Phone:325-944-4722
Practice Address - Fax:325-223-1150
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22463103T00000X
TX6094103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00GK54OtherBCBS
TX00D13PMedicare ID - Type Unspecified