Provider Demographics
NPI:1932319571
Name:BURBANK, BENNETT (LCSW, CAP)
Entity Type:Individual
Prefix:MR
First Name:BENNETT
Middle Name:
Last Name:BURBANK
Suffix:
Gender:M
Credentials:LCSW, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N ROCKY POINT DR STE 650
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5999
Mailing Address - Country:US
Mailing Address - Phone:800-892-0640
Mailing Address - Fax:
Practice Address - Street 1:2701 N ROCKY POINT DR STE 650
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-5999
Practice Address - Country:US
Practice Address - Phone:800-892-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 75801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical