Healthcare Provider Details

I. General information

NPI: 1932136751
Provider Name (Legal Business Name): TERESA LYNN WALDROP BURNETT LCSW, MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8937 S GARNETT RD
BROKEN ARROW OK
74012-6018
US

IV. Provider business mailing address

8937 S GARNETT RD
BROKEN ARROW OK
74012-6018
US

V. Phone/Fax

Practice location:
  • Phone: 918-872-9777
  • Fax: 918-872-9779
Mailing address:
  • Phone: 918-872-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number00810
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1542
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: