Provider Demographics
NPI:1336986652
Name:BURNETT, NICHOLAS (LPC-IT, SAC-IT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BURNETT
Suffix:
Gender:M
Credentials:LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1208
Mailing Address - Country:US
Mailing Address - Phone:920-231-0143
Mailing Address - Fax:
Practice Address - Street 1:3240 JACKSON ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-1208
Practice Address - Country:US
Practice Address - Phone:920-231-0143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20615-130101YA0400X
WI7912-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)