Healthcare Provider Details

I. General information

NPI: 1124712377
Provider Name (Legal Business Name): RANDALL JOSEPH BURNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR STE 300
GRESHAM OR
97030-3725
US

IV. Provider business mailing address

11035 NE SANDY BLVD
PORTLAND OR
97220-2553
US

V. Phone/Fax

Practice location:
  • Phone: 460-050-3258
  • Fax:
Mailing address:
  • Phone: 503-258-4200
  • Fax: 503-258-4200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: