Provider Demographics
NPI:1871842237
Name:BURTON, DERRICK KEITH
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:KEITH
Last Name:BURTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 W 81ST ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-2338
Mailing Address - Country:US
Mailing Address - Phone:714-906-7730
Mailing Address - Fax:
Practice Address - Street 1:66 HURLBUT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-4025
Practice Address - Country:US
Practice Address - Phone:626-254-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1003311134101YA0400X
CACATUS1-1362-010914S101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)