Healthcare Provider Details

I. General information

NPI: 1053805325
Provider Name (Legal Business Name): NICOLE BURT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 N 16TH ST STE 110
PHOENIX AZ
85020-4446
US

IV. Provider business mailing address

7600 N 16TH ST STE 110
PHOENIX AZ
85020-4446
US

V. Phone/Fax

Practice location:
  • Phone: 602-615-0381
  • Fax:
Mailing address:
  • Phone: 602-615-0381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number4975
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: