Provider Demographics
NPI:1992045777
Name:BURRIS, BENNISA MICHELLE
Entity Type:Individual
Prefix:
First Name:BENNISA
Middle Name:MICHELLE
Last Name:BURRIS
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 1:2624 N QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-2604
Mailing Address - Country:US
Mailing Address - Phone:918-949-1904
Mailing Address - Fax:
Practice Address - Street 1:5555 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-7104
Practice Address - Country:US
Practice Address - Phone:918-779-4556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst