Provider Demographics
NPI:1811051261
Name:BURKS, NANCY ALICE (PHD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:ALICE
Last Name:BURKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2051
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-2051
Mailing Address - Country:US
Mailing Address - Phone:734-973-2766
Mailing Address - Fax:
Practice Address - Street 1:2048 WASHTENAW RD
Practice Address - Street 2:SUITE LL
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1889
Practice Address - Country:US
Practice Address - Phone:734-649-2127
Practice Address - Fax:734-973-2766
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011334103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP22760Medicare ID - Type Unspecified