Provider Demographics
NPI:1063561157
Name:BURNETT, CAROLYN H (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:H
Last Name:BURNETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 COUNTY ROAD 3849
Mailing Address - Street 2:
Mailing Address - City:JOAQUIN
Mailing Address - State:TX
Mailing Address - Zip Code:75954-3342
Mailing Address - Country:US
Mailing Address - Phone:936-554-2388
Mailing Address - Fax:
Practice Address - Street 1:157 WALL ST
Practice Address - Street 2:
Practice Address - City:TENAHA
Practice Address - State:TX
Practice Address - Zip Code:75974-5413
Practice Address - Country:US
Practice Address - Phone:936-248-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX394931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185639501Medicaid
TX185639502Medicaid
TX185639502Medicaid