Healthcare Provider Details

I. General information

NPI: 1063561157
Provider Name (Legal Business Name): CAROLYN H BURNETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 WALL ST
TENAHA TX
75974-5413
US

IV. Provider business mailing address

900 COUNTY ROAD 3849
JOAQUIN TX
75954-3342
US

V. Phone/Fax

Practice location:
  • Phone: 936-248-4673
  • Fax:
Mailing address:
  • Phone: 936-554-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number39493
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: