Provider Demographics
NPI:1689856627
Name:BURKETT, MARTHA DORAN (LPC, NCC, CAADC,ADS)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:DORAN
Last Name:BURKETT
Suffix:
Gender:F
Credentials:LPC, NCC, CAADC,ADS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 BURTON ST SE STE 104
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4833
Mailing Address - Country:US
Mailing Address - Phone:616-542-4211
Mailing Address - Fax:
Practice Address - Street 1:2424 BURTON ST SE STE 104
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4833
Practice Address - Country:US
Practice Address - Phone:616-541-4211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-01
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-00076101YA0400X
MI6401009140101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401009140OtherCOUNSELING LICENSE
5797OtherNATIONAL AURICULAR ACUDETOX ASSOCIATION ADS CERTIFICATE
11806665OtherCAQH
95289OtherNCC
MIC-00076OtherCAADC