Provider Demographics
NPI:1194739334
Name:BURNSIDE, MICHAEL KEITH (LPC, LADC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:OK
Mailing Address - Zip Code:74445-2224
Mailing Address - Country:US
Mailing Address - Phone:918-733-4603
Mailing Address - Fax:
Practice Address - Street 1:100 W 7TH ST STE 102
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5007
Practice Address - Country:US
Practice Address - Phone:918-758-1910
Practice Address - Fax:918-756-1270
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK553101YA0400X
OK2650101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK300522336OtherMEDICARE