Healthcare Provider Details

I. General information

NPI: 1902917933
Provider Name (Legal Business Name): JEANNIE S BURDICK M.A. CLINICAL PSYCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 BOYCE RD
CORFU NY
14036-9742
US

IV. Provider business mailing address

8801 BOYCE RD
CORFU NY
14036-9742
US

V. Phone/Fax

Practice location:
  • Phone: 585-343-0055
  • Fax:
Mailing address:
  • Phone: 585-343-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001111-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: