Basic Information
| Provider Information | |||||||||
| NPI: | 1902418684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKHARDT | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 414 FLAGLER BLVD | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320803736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043255886 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5776 SAINT AUGUSTINE RD # 8030 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044484700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2020 | ||||||||
| LastUpdateDate: | 08/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.