Provider Demographics
NPI:1316070022
Name:BURKS, CAROL JEAN (MS, LPC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:BURKS
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 RIVERSIDE DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-1907
Mailing Address - Country:US
Mailing Address - Phone:920-430-9100
Mailing Address - Fax:920-430-9101
Practice Address - Street 1:2301 RIVERSIDE DR
Practice Address - Street 2:SUITE 8
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-1907
Practice Address - Country:US
Practice Address - Phone:920-430-9100
Practice Address - Fax:920-430-9101
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2997-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43583600Medicaid