Provider Demographics
NPI:1487169744
Name:BURDINE, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BURDINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15161 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MIDWAY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92655-1432
Mailing Address - Country:US
Mailing Address - Phone:949-273-0555
Mailing Address - Fax:
Practice Address - Street 1:15161 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MIDWAY CITY
Practice Address - State:CA
Practice Address - Zip Code:92655-1432
Practice Address - Country:US
Practice Address - Phone:949-273-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA762041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA76204OtherBBS
CA76204OtherACSW