Healthcare Provider Details

I. General information

NPI: 1972604155
Provider Name (Legal Business Name): ANDREA DENISE BURT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9990 COUNTY FARM RD
RIVERSIDE CA
92503-3542
US

IV. Provider business mailing address

13014 MAXWELL DR
TUSTIN CA
92782-0918
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4840
  • Fax: 951-358-4848
Mailing address:
  • Phone: 714-838-1939
  • Fax: 951-358-4848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS20412
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: