Healthcare Provider Details

I. General information

NPI: 1053758300
Provider Name (Legal Business Name): CARRIE A BURRIS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 W RAILROAD AVE SUITE 16
RAY ND
58849
US

IV. Provider business mailing address

1500 14TH ST W STE 290
WILLISTON ND
58801-4078
US

V. Phone/Fax

Practice location:
  • Phone: 701-568-5600
  • Fax:
Mailing address:
  • Phone: 701-334-6442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-35774
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5619
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5619
Identifier TypeOTHER
Identifier StateND
Identifier IssuerND BOARD OF SW EXAMINERS
# 2
IdentifierLCSW-35774
Identifier TypeOTHER
Identifier StateID
Identifier IssuerID BUREAU OF OCCUPATIONAL LICENSES

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: