Healthcare Provider Details

I. General information

NPI: 1346568300
Provider Name (Legal Business Name): LAUREL IANNE BURNETT NCC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 LOUISIANA BLVD NE SOUTH BUILDING, SUITE #260
ALBUQUERQUE NM
87110-3532
US

IV. Provider business mailing address

PO BOX 51561
ALBUQUERQUE NM
87181-1561
US

V. Phone/Fax

Practice location:
  • Phone: 505-974-0104
  • Fax:
Mailing address:
  • Phone: 505-503-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0122271
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: