Provider Demographics
NPI:1902418684
Name:BURKHARDT, MOLLY ANN
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:BURKHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 FLAGLER BLVD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3736
Mailing Address - Country:US
Mailing Address - Phone:904-325-5886
Mailing Address - Fax:
Practice Address - Street 1:5776 SAINT AUGUSTINE RD # 8030
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8046
Practice Address - Country:US
Practice Address - Phone:904-448-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health