Healthcare Provider Details

I. General information

NPI: 1043878408
Provider Name (Legal Business Name): COSSETTE BURNHAM DPT, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 05/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FOUR PINES PHYSICAL THERAPY 1090 S HWY 89
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 8467
JACKSON WY
83002-8467
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-5577
  • Fax:
Mailing address:
  • Phone: 406-439-8035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT-1869
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: