Provider Demographics
NPI:1518210079
Name:BURTON, ELVIN THOMASEO (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELVIN
Middle Name:THOMASEO
Last Name:BURTON
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 1:186 MARKET ST # 310
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3537
Mailing Address - Country:US
Mailing Address - Phone:617-445-1579
Mailing Address - Fax:
Practice Address - Street 1:51 N DUNLAP ST
Practice Address - Street 2:STE. G145
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-4625
Practice Address - Country:US
Practice Address - Phone:901-287-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3295103TC0700X
MA9642103TC0700X
PAPS019677103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014670Medicaid
TNQ014670Medicaid