Provider Demographics
NPI:1154401446
Name:BURKS, RONALD (PMH 823)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:BURKS
Suffix:
Gender:M
Credentials:PMH 823
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8894 WAUKEENAH HWY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-7075
Mailing Address - Country:US
Mailing Address - Phone:850-997-2445
Mailing Address - Fax:
Practice Address - Street 1:1616 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4619
Practice Address - Country:US
Practice Address - Phone:850-431-5144
Practice Address - Fax:850-431-6105
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9433101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)