Provider Demographics
NPI:1124795653
Name:BURNETT, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:WATTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1351 WHETSTONE DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-2680
Mailing Address - Country:US
Mailing Address - Phone:317-956-9765
Mailing Address - Fax:
Practice Address - Street 1:1351 WHETSTONE DR
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-2680
Practice Address - Country:US
Practice Address - Phone:317-956-9765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator