=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154487882
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNIE BURNETT LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 07/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 PARK AVE
-----------------------------------------------------
City | COOS BAY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97420-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-925-1313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73495 HIGHWAY 101
-----------------------------------------------------
City | NORTH BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97459-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-925-1313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1158
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C4806
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------