Provider Demographics
NPI:1578868808
Name:MICHAEL T. BURNS, PSY.D LTD
Entity Type:Organization
Organization Name:MICHAEL T. BURNS, PSY.D LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:815-455-0044
Mailing Address - Street 1:610 CRYSTAL POINT DR STE 3
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-1400
Mailing Address - Country:US
Mailing Address - Phone:815-455-0044
Mailing Address - Fax:815-455-0080
Practice Address - Street 1:610 CRYSTAL POINT DR STE 3
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1400
Practice Address - Country:US
Practice Address - Phone:815-455-0044
Practice Address - Fax:815-455-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004478251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL632360Medicare PIN