Healthcare Provider Details

I. General information

NPI: 1922709559
Provider Name (Legal Business Name): CAROLYN BLAIR BURNETTE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 WEST ST
LANSING MI
48915-1127
US

IV. Provider business mailing address

411 WEST ST
LANSING MI
48915-1127
US

V. Phone/Fax

Practice location:
  • Phone: 615-308-4769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301019260
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: