Provider Demographics
NPI:1629353057
Name:BURKHOLDER, MICHAEL DAVID (MA, LMFT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:BURKHOLDER
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 N 3RD ST
Mailing Address - Street 2:SUITE 5-B
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3145
Mailing Address - Country:US
Mailing Address - Phone:208-667-9145
Mailing Address - Fax:
Practice Address - Street 1:1034 N 3RD ST
Practice Address - Street 2:SUITE 5-B
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3145
Practice Address - Country:US
Practice Address - Phone:208-667-9145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT 2680106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist