Provider Demographics
NPI:1821596719
Name:BURKHOLDER, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BURKHOLDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8807 SCANDINAVIA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-1745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8807 SCANDINAVIA BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-1745
Practice Address - Country:US
Practice Address - Phone:863-398-8021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
FL101YS0200X
FLIMH12078101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool