Provider Demographics
NPI:1174671879
Name:BURKS, CAROL R (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:R
Last Name:BURKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PERKINS DR
Mailing Address - Street 2:STE. C
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3248
Mailing Address - Country:US
Mailing Address - Phone:505-524-8404
Mailing Address - Fax:505-524-8406
Practice Address - Street 1:301 PERKINS DR
Practice Address - Street 2:STE. C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3248
Practice Address - Country:US
Practice Address - Phone:505-524-8404
Practice Address - Fax:505-524-8406
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM651103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMVNM0038OtherVALUE OPTIONS
NMNM100989Medicaid
NMNM01NL36OtherBCBS OF NM