Basic Information
| Provider Information | |||||||||
| NPI: | 1316025711 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ-BURKE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC, LCAS, CRC, MTBC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2385 BROCK AVE | ||||||||
| Address2: | |||||||||
| City: | WINTERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285909310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523411649 | ||||||||
| FaxNumber: | 2523531119 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 W FIRETOWER RD | ||||||||
| Address2: | |||||||||
| City: | WINTERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285909475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523411649 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1040 | NC | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 5198 | NC | X | Behavioral Health & Social Service Providers | Counselor | Professional | 225A00000X | 06087 | NC | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Music Therapist | 101YM0800X | 5198 | NC | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225C00000X | 00090419 | NC | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |
ID Information
| ID | Type | State | Issuer | Description | 142HR | 01 | NC | LPC | OTHER | 6103146 | 05 | NC | MEDICAID |