Healthcare Provider Details

I. General information

NPI: 1144558156
Provider Name (Legal Business Name): MALLORY HELEN BURNETT M.A. LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2469 CORRALES ROAD N.W.
CORRALES NM
87048-7530
US

IV. Provider business mailing address

47 DESERT WILLOW RD
CORRALES NM
87048-7530
US

V. Phone/Fax

Practice location:
  • Phone: 505-717-9552
  • Fax: 505-369-1121
Mailing address:
  • Phone: 505-717-9552
  • Fax: 505-369-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0127561
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC0150041
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: