Provider Demographics
NPI:1396801478
Name:BURNS, DARRELL DEAN (MS)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:DEAN
Last Name:BURNS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 N 14TH ST # 114
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-4654
Mailing Address - Country:US
Mailing Address - Phone:580-763-4092
Mailing Address - Fax:
Practice Address - Street 1:1500 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2827
Practice Address - Country:US
Practice Address - Phone:580-763-4092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1096101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health