Provider Demographics
NPI:1639219470
Name:BURKS, ANGELA BETH (LCMFT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:BETH
Last Name:BURKS
Suffix:
Gender:F
Credentials:LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 N DOREEN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1621
Mailing Address - Country:US
Mailing Address - Phone:316-519-8479
Mailing Address - Fax:
Practice Address - Street 1:111 S WHITTIER RD
Practice Address - Street 2:# 4000C
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-1045
Practice Address - Country:US
Practice Address - Phone:316-689-3500
Practice Address - Fax:316-689-3599
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS316106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS203229129OtherTIN