Healthcare Provider Details

I. General information

NPI: 1235536699
Provider Name (Legal Business Name): CASEY BURNETT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 IRIS AVE
BOULDER CO
80304-2226
US

IV. Provider business mailing address

1333 IRIS AVE
BOULDER CO
80304-2226
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8500
  • Fax:
Mailing address:
  • Phone: 303-443-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0012207
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: