Basic Information
| Provider Information | |||||||||
| NPI: | 1285905083 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CYVIL B. BURKS, SR., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12883 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731572883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058580600 | ||||||||
| FaxNumber: | 4058580602 | ||||||||
| Practice Location | |||||||||
| Address1: | 2212 NW 50TH ST | ||||||||
| Address2: | SUITE 172C | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731128086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058085229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2012 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | BURKS | ||||||||
| AuthorizedOfficialFirstName: | CYVIL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4058085229 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1327 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.