Provider Demographics
NPI:1285983106
Name:BURNETT, DAVID KEVIN (MSW)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:KEVIN
Last Name:BURNETT
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SOUTH HOLLY STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501
Mailing Address - Country:US
Mailing Address - Phone:541-774-8200
Mailing Address - Fax:541-774-7964
Practice Address - Street 1:140 SOUTH HOLLY STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-774-8200
Practice Address - Fax:541-774-7964
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA5098101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health