Healthcare Provider Details

I. General information

NPI: 1225315278
Provider Name (Legal Business Name): TARA BURNETT MS, LAT/ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 ROBERT DEDMAN DR
AUSTIN TX
78712-1505
US

IV. Provider business mailing address

PO BOX 7399
AUSTIN TX
78713-7399
US

V. Phone/Fax

Practice location:
  • Phone: 512-471-5513
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT3764
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: