Provider Demographics
NPI:1215504535
Name:BURLESON, RICHARD CARROLL
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:CARROLL
Last Name:BURLESON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 STIEGER LAKE LN
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-7723
Mailing Address - Country:US
Mailing Address - Phone:952-322-4603
Mailing Address - Fax:651-322-4603
Practice Address - Street 1:15265 CARROUSEL WAY
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-1760
Practice Address - Country:US
Practice Address - Phone:952-433-4600
Practice Address - Fax:651-322-4603
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-06
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4845101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional