Provider Demographics
NPI:1700649787
Name:BURBANK, MORIAH SKY (ALC)
Entity Type:Individual
Prefix:
First Name:MORIAH
Middle Name:SKY
Last Name:BURBANK
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 49TH PL S APT A
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35222-3826
Mailing Address - Country:US
Mailing Address - Phone:205-864-7096
Mailing Address - Fax:
Practice Address - Street 1:2101 6TH AVE N STE 1125
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35203-2771
Practice Address - Country:US
Practice Address - Phone:205-319-6459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04786101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional