Provider Demographics
NPI:1528649118
Name:BURNETT, OCTAVIUS
Entity type:Individual
Prefix:
First Name:OCTAVIUS
Middle Name:
Last Name:BURNETT
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 1:1931 DAYBREAK CIR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-9001
Mailing Address - Country:US
Mailing Address - Phone:215-384-4512
Mailing Address - Fax:
Practice Address - Street 1:1931 DAYBREAK CIR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-9001
Practice Address - Country:US
Practice Address - Phone:215-384-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH004937101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health