Provider Demographics
NPI:1104814789
Name:BURCKHARD, MIKE VINCENT (LICSW)
Entity type:Individual
Prefix:MR
First Name:MIKE
Middle Name:VINCENT
Last Name:BURCKHARD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 MAIN ST S STE 315
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3956
Mailing Address - Country:US
Mailing Address - Phone:701-852-5876
Mailing Address - Fax:701-852-5883
Practice Address - Street 1:315 MAIN ST S
Practice Address - Street 2:SUITE 315
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3956
Practice Address - Country:US
Practice Address - Phone:701-852-5876
Practice Address - Fax:701-852-5883
Is Sole Proprietor?:No
Enumeration Date:2005-10-08
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND120101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17415OtherBLUE CROSS ID NUMBER
ND19118Medicaid
ND17415Medicare PIN