Provider Demographics
NPI:1245500826
Name:BURKS, MICHELLE MARIE (CADC LPC)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:BURKS
Suffix:
Gender:F
Credentials:CADC LPC
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:BURKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC, CADC
Mailing Address - Street 1:1500 E HERITAGE PARK ST STE 150
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5800
Mailing Address - Country:US
Mailing Address - Phone:082-631-0843
Mailing Address - Fax:208-906-0807
Practice Address - Street 1:1500 E HERITAGE PARK ST STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5800
Practice Address - Country:US
Practice Address - Phone:082-631-0843
Practice Address - Fax:208-906-0807
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC6211101YM0800X
IDLPC5032305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1245500826Medicaid