Provider Demographics
NPI:1356221568
Name:BURNSIDE, NATHEN L
Entity type:Individual
Prefix:
First Name:NATHEN
Middle Name:L
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 W GORDON RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-6794
Mailing Address - Country:US
Mailing Address - Phone:888-714-1927
Mailing Address - Fax:317-272-6811
Practice Address - Street 1:6655 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8923
Practice Address - Country:US
Practice Address - Phone:888-714-1927
Practice Address - Fax:317-272-6811
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health