MEDICARE: MR. ROBERT S BURNSIDE LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I-05142	NM

General Provider Information

NPI Number	:	1962725945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT S BURNSIDE LISW

Provider Business Mailing Address
First Line	:	4800 COLLEGE BLVD
Second Line	:	SUITE 102
City	:	FARMINGTON
State	:	NM
Zip	:	87402-4710
Country	:	US
Telephone Number	:	505-326-3566
Fax Number	:	505-326-5698

Provider Business Practice Location Address
First Line	:	4800 COLLEGE BLVD
Second Line	:	SUITE 102
City	:	FARMINGTON
State	:	NM
Zip	:	87402-4710
Country	:	US
Telephone Number	:	505-326-3566
Fax Number	:	505-326-5698

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2010
Last Update Date	:	03/05/2010

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Directions to “ MR. ROBERT S BURNSIDE LISW” Practice Location

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